NURSING ASSISTANT

Myra Sandquist Reuter

Chippewa Valley Technical College
Nursing Assistant (Reuter)
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TABLE OF CONTENTS
Introduction
Licensing
Preface
Foundational Concepts

Licensing

1: Communicate Professionally Within a Health Care Setting

1.1: Introduction to Communicate Professionally Within A Health Care Setting
1.2: The Communication Process
1.3: Communication Within the Health Care Team
1.4: Human Needs and Developmental Stages
1.5: Documenting and Reporting
1.6: Learning Activities
1.7: I Glossary

2: Demonstrate Professionalism in the Workplace

2.1: Introduction to Demonstrate Professionalism in the Workplace
2.2: Ethical and Legal Responsibilities of the Nursing Assistant
2.3: Members of the Health Care Team and Nursing Home Structure
2.4: The Nursing Process
2.5: Scope of Practice
2.6: Health Care Settings
2.7: Job-Seeking and Keeping Skills
2.8: Learning Activities
2.9: II Glossary

3: Maintain a Safe Health Care Environment

3.1: Introduction to Maintain a Safe Health Care Environment
3.2: Emergency Situations
3.3: Resident Environment
3.4: Body Mechanics and Safe Equipment Use
3.5: Skills Checklist- Making an Unoccupied Bed Checklist
3.6: Skills Checklist- Making an Occupied Bed
3.7: Learning Activities
3.8: III Glossary

4: Adhere to Principles of Infection Control

4.1: Introduction to Adhere to Principles of Infection Control
4.2: Chain of Infection
4.3: Defenses Against Transmission of Infection
4.4: Precautions Used to Prevent the Spread of Infection
4.5: Personal Protective Equipment (PPE)
4.6: Blood-borne Pathogen Standard

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 4.7: Signs and Symptoms of Infection
4.8: Skills Checklist- Hand Hygiene With Soap and Water
4.9: Skills Checklist- Hand Hygiene With Alcohol-Based Hand Sanitizer
4.10: Skills Checklist- Removing Gloves
4.11: Skills Checklist- Donning/Doffing PPE Without a Mask
4.12: Skills Checklist- Donning/Doffing PPE With a Mask and Face Shield or Goggles
4.13: Learning Activities
4.14: IV Glossary

5: Provide for Personal Care Needs of Clients

5.1: Introduction to Provide for Personal Care Needs of Clients
5.2: Activities of Daily Living (ADLs)
5.3: Person-Centered Care
5.4: Pre- and Post-Procedural Steps
5.5: Skin Care
5.6: Types of Baths and Techniques
5.7: Assisting With Nutrition and Fluid Needs
5.8: Assistance With Toileting
5.9: Skills Checklist- Partial Bath
5.10: Skills Checklist- Full Bed Bath
5.11: Skills Checklist- Shower
5.12: Skills Checklist- Tub Bath
5.13: Skills Checklist- Shampoo
5.14: Skills Checklist- Foot Care
5.15: Skills Checklist- Nail Care
5.16: Skills Checklist- Skin Care
5.17: Skills Checklist- Back Rub
5.18: Skills Checklist- Perineal Care (Female)
5.19: Skills Checklist- Perineal Care (Male)
5.20: Skills Checklist- Oral Care
5.21: Skills Checklist- Denture Care
5.22: Skills Checklist- Preparing Clients for Meals and Assisting With Feeding
5.23: Skills Checklist- Choking Maneuver
5.24: Skills Checklist- Catheter Care
5.25: Skills Checklist- Emptying Catheter Drainage Bag
5.26: Skills Checklist- Assisting With a Bedpan
5.27: Skills Checklist- Assisting With a Urinal
5.28: Skills Checklist- Changing Incontinence Brief
5.29: Skills Checklist- Dressing A Client Who Needs Total Assistance
5.30: Skills Checklist- Shaving With an Electric Razor
5.31: Learning Activities
5.32: V Glossary

6: Provide for Basic Nursing Care Needs

6.1: Introduction to Provide for Basic Nursing Care Needs
6.2: Nutrition and Fluid Needs
6.3: Pain
6.4: Comfort Measures
6.5: Effects of Prescribed Routine Medications
6.6: End-of-Life Care
6.7: Postmortem Care

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 6.8: Skills Checklist- Topical Medications
6.9: Learning Activities
6.10: VI Glossary

7: Demonstrate Reporting and Documentation of Client Data

7.1: Introduction to Demonstrate Reporting and Documentation of Client Data
7.2: Documenting and Reporting Data
7.3: Recognizing Signs of Client Discomfort
7.4: Obtaining Vital Signs
7.5: Normal Ranges for Vital Signs
7.6: Measuring Weight and Height
7.7: Measuring Intake and Output
7.8: Skills Checklist- Oral, Tympanic, Axillary, Rectal and Temporal Temperatures
7.9: Skills Checklist- Pulse
7.10: Skills Checklist- Respirations
7.11: Skills Checklist- Measuring Height for Ambulatory Residents
7.12: Skills Checklist- Measuring Weight for Ambulatory Residents
7.13: Learning Activities
7.14: VII Glossary

8: Utilize Principles of Mobility to Assist Clients

8.1: Introduction to Utilize Principles of Mobility to Assist Clients
8.2: Moving and Positioning Clients
8.3: Promoting Joint Mobility and Activity
8.4: Assisting Clients to Transfer
8.5: Assisting With Ambulation
8.6: Applying Prosthetics and Orthotics
8.7: Restraints and Restraint Alternatives
8.8: Skills Checklist- Positioning Supine to Lateral (Side-Lying)
8.9: Skills Checklist- Transfer From Bed to Chair With a Gait Belt
8.10: Skills Checklist- Transfer From Bed to Chair With Sit-to-Stand
8.11: Skills Checklist- Transfer From Bed to Chair With Mechanical Lift
8.12: Skills Checklist- Ambulation From Wheelchair
8.13: Learning Activities
8.14: VIII Glossary

9: Promote Independence Through Rehabilitation/Restorative Care

9.1: Introduction to Promote Independence Through Rehabilitation/Restorative Care
9.2: The Rehabilitation Process
9.3: Members of the Therapy Team
9.4: Complications of Immobility
9.5: Rehabilitation Versus Restorative Care
9.6: Promoting Independence During ADLs
9.7: Assisting With Sensory Deficits
9.8: Fall Prevention
9.9: Skills Checklist- Range of Motion (ROM) Exercises for the Shoulder
9.10: Skills Checklist- Range of Motion (ROM) for the Hip and Knee
9.11: Skills Checklist- Application of Compression Stockings (TED Hose)
9.12: Learning Activities
9.13: IX Glossary

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10: Provide Care for Clients Experiencing Acute and Chronic Health
Conditions
10.1: Introduction to Provide Care for Clients Experiencing Acute and Chronic Conditions
10.2: History of Care for Individuals With Mental Health Disorders and Developmental Disorders
10.3: Caring for Clients With Developmental Disorders
10.4: Caring for Clients With Mental Health or Substance Use Disorders
10.5: Caring for Clients With Dementia
10.6: Promoting Nutritional Intake
10.7: Caregiver Role Strain
10.8: Learning Activities
10.9: X Glossary

11: Apply Knowledge of Body Systems to Client Care

11.1: Introduction to Apply Knowledge of Body Systems to Client Care
11.2: Cardiovascular System
11.3: Digestive System
11.4: Endocrine System
11.5: Integumentary System
11.6: Musculoskeletal System
11.7: Urinary System
11.8: Neurological System
11.9: Immune System
11.10: Respiratory System
11.11: Reproductive System
11.12: Learning Activities
11.13: XI Glossary

Index
Glossary

Detailed Licensing

Detailed Licensing

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Introduction
This textbook is an open educational resource (OER) with CC-BY licensing developed for students in the Wisconsin Technical
College System’s Nursing Assistant program (30-543-300). The Nursing Assistant program prepares students for employment as
nursing assistants, as well as for entry to other health-related programs. Students are required to demonstrate the following skills
under the supervision of a licensed nurse upon completion of the course: communication, basic nursing assistant and personal care
skills, attention to clients’ rights, and care of clients with dementias. The program is recognized by the Wisconsin Department of
Health Services as a nurse aide training program. Upon successful completion of the program, the student is eligible to take the
Wisconsin Nursing Assistant competency evaluation for inclusion on the Wisconsin Nurse Aide Registry and employment in
nursing homes, hospitals, home health agencies, hospices, community based residential facilities, assisted living centers, and homes
for the developmentally disabled.
Chippewa Valley Technical College created this OER with Higher Education Emergency Relief Funding (HEERF) by using Open
RN workflows and remixing Open RN OER textbooks. The Open RN project is supported by a $2.5 million grant from the
Department of Education. More information about the Open RN project can be found at cvtc.edu/OpenRN.
This e-book is available for free online and can also be downloaded in multiple formats for offline use. The online version is
required for interaction with adaptive learning activities included in each chapter. The following video provides a quick overview
of how to navigate the online version.
One or more interactive elements has been excluded from this version of the text. You can view them online here:
https://wtcs.pressbooks.pub/nurseassist/?p=4#oembed-1

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Licensing
A detailed breakdown of this resource's licensing can be found in Back Matter/Detailed Licensing.

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Preface
Developing Author
The developing author remixed existing open educational resources and developed original content.
Myra Reuter Sandquist, MA, RN, Chippewa Valley Technical College

Editors
Kimberly Ernstmeyer, MSN, RN, CNE, CHSE, APNP-BC, Chippewa Valley Technical College
Dr. Elizabeth Christman, DNP, RN, CNE

Graphics Editor
Nic Ashman, MLIS, Librarian, Chippewa Valley Technical College

Copy Editor
Jane Flesher, MST, Proofreader, Chippewa Valley Technical College

Reviewers
Lynn Barton, MSN, RN, Oregon Coast Community College
Dr. Kathleen Capone, MS, RN, CNE, EdD, Nurses International
Tammy Casey, RN, Chippewa Valley Technical College
Tamara Davis, MSN, RN, Chippewa Valley Technical College
Marie E. Dusio, MS, RN, Madison Area Technical College
Stacey Grimm, BSN, RN, Lakeshore Technical College
Magdalena Handy, RN, South Texas College
Jill Henry, RN, Southwest Wisconsin Technical College
Dr. Amy Olson, DNP, RN, Mayo Clinic
Celee Schuch, Certified Nursing Assistant and Nursing Student, St. Catherine University
Cynthia Theys, MSN, RN, MSOLQ, Northeast Wisconsin Technical College
Gerri Van Oss, BSN, RN, Lakeshore Technical College
Dr. Nancy Whitehead, PhD, RN, APNP, Milwaukee Area Technical College
Amanda Yule, BSN, RN, Chippewa Valley Technical College

Licensing/Terms of Use
This textbook is licensed under a Creative Commons Attribution 4.0 International (CC-BY) license unless otherwise indicated,
which means that you are free to:
SHARE – copy and redistribute the material in any medium or format
ADAPT – remix, transform, and build upon the material for any purpose, even commercially
The licensor cannot revoke these freedoms as long as you follow the license terms.
Attribution: You must give appropriate credit, provide a link to the license, and indicate if any changes were made. You may do
so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
No Additional Restrictions: You may not apply legal terms or technological measures that legally restrict others from doing
anything the license permits.
Notice: You do not have to comply with the license for elements of the material in the public domain or where your use is
permitted by an applicable exception or limitation.
No Warranties Are Given: The license may not give you all of the permissions necessary for your intended use. For example,
other rights such as publicity, privacy, or moral rights may limit how you use the material.

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Attribution
Content for this textbook was adapted from the following open educational resources. For specific reference information about
what was used and/or changed in this adaptation, please refer to the footnotes at the bottom of each page of the book.
Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0
Nursing Skills by Chippewa Valley Technical College is licensed under CC BY 4.0
Nursing Pharmacology by Chippewa Valley Technical College is licensed under CC BY 4.0
Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College is licensed under CC BY 4.0
Human Relations by LibreTexts is licensed under CC BY-NC-SA 4.0
Microbiology by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-
introduction
Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant,
Cosgrove, & Sharpe is licensed under CC BY-NC 4.0
Anatomy and Physiology by Boundless is licensed under CC BY-SA 4.0
Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
Nursing Care at the End of Life by Lowey is licensed under CC BY-NC-SA 4.0
StatPearls by McNeil-Masuka and Boyer is licensed under CC BY 4.0
StatPearls by Waheed, Kudaravalli, and Hotwagner is licensed under CC BY 4.0
Introduction to Sensation and Perception by Students of PSY 3031 and edited by Dr. Cheryl Olman is licensed under CC BY
4.0
Introduction to Social Work at Ferris State University by Department of Social Work is licensed under CC BY 4.0
What is the Individuals With Disabilities Education Act? by University of Washington is licensed under CC BY-NC-SA 3.0
Psychology by Jeffrey C. Levy is licensed under CC BY 4.0
Understanding and Supporting Learners With Disabilities by Paula Lombardi is licensed under CC BY-NC-SA 4.0
Abnormal Psychology by Lumen Learning is licensed under CC BY 4.0
A Long Goodbye: Ed and Mary’s Journey With Lewy Body Dementia by James Cook University is licensed under CC BY-NC-
ND 4.0
StatPearls by Khan and De Jesus is licensed under CC BY 4.0
Opening Eyes Onto Inclusion and Diversity by Carter (Ed.) is licensed under CC BY-NC 4.0
The Scholarship of Writing in Nursing Education: 1st Canadian Edition by Lapum, St-Amant, Hughes, Tan, Bogdan,
Dimaranan, Frantzke, and Savicevic is licensed under CC BY-SA 4.0
Suggested attribution statement: Reuter-Sandquist, Myra. (2022). Nursing Assistant (K. Ernstmeyer and E. Christman, Eds.) by
Chippewa Valley Technical College is licensed under CC BY 4.0

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Foundational Concepts
Nursing assistants (NAs), also called nursing aides, are important members of the health care team. NAs work under the
supervision of licensed practical/vocational nurses (LPNs/VNs) and registered nurses (RNs).
[1]
NAs provide basic care and help patients* with activities of daily living. They typically perform the following tasks :
Clean and bathe patients
Help patients use the toilet and dress
Turn, reposition, and transfer patients between beds and wheelchairs
Listen to and record patients’ health concerns and report that information to nurses
Measure patients’ vital signs, such as temperature
Serve meals and help patients eat
* Note: The terms patient, client, and resident are used interchangeably throughout this book to represent the people cared for by
nursing assistants. Definitions of these terms are discussed in Chapter 2.6, “Health Care Settings.”
Each state defines the actions and skills that nursing assistants can perform in health care facilities, also referred to as their scope of
practice. Job descriptions in health care agencies also list specific expectations and duties for NAs within that facility. Depending
on the NA’s level of training, the facility, and the state law in which they work, nursing assistants may also dispense medication.
These actions and associated skills checkoffs will be discussed throughout this book.
[2]
View the following YouTube video about Nursing Assistants : Certified Nursing Assistant Career.
In 2020, nursing assistants were employed in 1.4 million jobs in many types of health care facilities. The largest employers of
[3]
nursing assistants were as follows :
Skilled nursing facilities: 37%
Hospitals: 30%
Assisted-living facilities: 11%
Home health care agencies: 6%
Government agencies: 4%
Skilled nursing facilities (commonly referred to as “nursing homes”) provide inpatient services to patients who require medical,
nursing, or rehabilitative services but do not provide the level of care or treatment available in a hospital. Assisted-living facilities
are living arrangements where people live on their own in a residential facility but additional personal care services such as meals,
housekeeping, transportation, and assistance with activities of daily living are available. Residents in assisted living facilities
typically pay monthly rent with additional fees for requested services. Home health care agencies provide skilled nursing care,
[4]
physical therapy, occupational therapy, speech therapy, and personal care in an individual’s home. “Health care settings” are
further discussed in Chapter 2.
Overall employment of nursing assistants is projected to grow eight percent from 2020 to 2030. As the baby-boom population ages,
nursing assistants will help care for an increasing number of older adults who have chronic or progressive diseases, such as heart
disease and diabetes.
Client preferences and shifts in federal and state funding are also increasing the demand for home and community-based long-term
[5]
care, which should lead to increased opportunities for nursing assistants in home health and community rehabilitation services. .
Nursing assistants may work full time or part time. Because health care facilities provide patient care at all hours, nursing assistants
[6]
often work nights, weekends, and holidays.

Becoming a Nursing Assistant

To become a nursing assistant, an individual must complete a state-approved education program and pass their state’s competency
exam. A state-approved education program includes classroom instruction on nursing assistant principles, as well as supervised
clinical work. These educational programs are available in high schools, community colleges, vocational and technical schools,
hospitals, and nursing homes. Nursing assistants who pass their state’s competency exam are placed on a state registry. They must
[7]
be on this state registry to work in a skilled nursing facility.

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Professional Qualities of a Nursing Assistant
As personal caregivers, nursing assistants must demonstrate professional qualities, including communication skills, compassion,
[8]
patience, and physical stamina :
Communication skills. Nursing assistants must listen and respond to patients’ concerns. They must appropriately share
observed patient information with nurses and other health care workers caring for that patient. Communicating professionally in
a health care setting is discussed in Chapter 1.
Empathy. Nursing assistants care for people who are sick, injured, debilitated, cognitively impaired, or need assistance for
other reasons. A compassionate attitude is required to do this type of work.
Physical stamina. Nursing assistants spend much of their time on their feet performing tasks such as lifting or moving patients.
It is important to be in good physical condition to safely perform these tasks and avoid injury to oneself or others. “Body
mechanics and safe equipment use” are discussed in Chapter 3.
Professionalism. Repetitive tasks of cleaning, feeding, and bathing patients can be stressful. Nursing assistants must complete
these tasks with professionalism.
Nursing assistants have one of the highest rates of injuries and illnesses of all occupations from lifting and moving patients and
other physically demanding tasks. Nursing assistants typically complete a brief period of on-the-job training to learn about their
specific employer’s equipment, policies, and procedures, as well as training in how to properly lift people to reduce the risk of
[9]
injuries.

Professionalism
What does professionalism mean? Being professional means delivering patient care in a manner that is ethical, respectful,
competent, knowledgeable, and caring. Professional nursing assistants are committed to promoting clients’ dignity and well-being,
[10]
as well as displaying high standards of professional behavior. Good hygiene principles as a health care professional include the
following:
Wear clean scrubs every shift. Scrubs should be wrinkle-free and the correct size for a professional appearance.
Keep your hair clean and neatly combed. Long hair should be pulled back for safety and infection control purposes.
Keep nails clean and trimmed short. Most agencies do not permit nail polish or artificial nails. Long nails and nail polish harbor
microorganisms that can spread infection.
Get plenty of sleep before coming to work so you are alert at work.
Wear comfortable, closed-toe shoes with nonskid soles.
Do not wear jewelry for safety and infection control purposes. Some agencies permit wedding rings.
Do not wear perfume or strong-smelling deodorants or powders. Strong odors can cause nausea, headaches, or allergic reactions
in some patients, especially if they are not feeling well.
Follow agency policies regarding tattoos and piercings.
Always wear your name badge while at work.
Wear a watch with a second hand that is easily cleaned.
Carry a pen and paper in your pocket for taking client care notes to report or document.
Use effective coping skills to deal with stress at work, home, and school.
Notify your supervisor if you are not feeling well.

Overview of This Book

The chapters in this book discuss the following competencies that a student must demonstrate to successfully become a certified
nursing assistant:
Chapter 1: Communicate Professionally Within a Health Care Setting
Chapter 2: Demonstrate Professionalism in the Workplace
Chapter 3: Maintain a Safe Health Care Environment
Chapter 4: Adhere to Principles of Infection Control
Chapter 5: Provide for Personal Care Needs of Clients
Chapter 6: Provide for Basic Nursing Care Needs
Chapter 7: Demonstrate Reporting and Documentation of Client Data
Chapter 8: Utilize Principles of Mobility to Assist Clients

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 Chapter 9: Promote Independence Through Rehabilitation/Restorative Care
Chapter 10: Provide Care for Clients Experiencing Acute and Chronic Health Conditions
Chapter 11: Apply Knowledge of Body Systems to Client Care

1. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies.
https://www.bls.gov/ooh/healthcare/nursing-assistants.htm ↵
2. WVHCA. (2012, July 27). Certified nursing assistant career [Video]. YouTube. All rights reserved.
https://youtu.be/fRjNpjxnjYo ↵
3. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies.
https://www.bls.gov/ooh/healthcare/nursing-assistants.htm ↵
4. Centers for Medicare & Medicaid Services. https://www.cms.gov ↵
5. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies.
https://www.bls.gov/ooh/healthcare/nursing-assistants.htm ↵
6. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies.
https://www.bls.gov/ooh/healthcare/nursing-assistants.htm ↵
7. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies.
https://www.bls.gov/ooh/healthcare/nursing-assistants.htm ↵
8. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies.
https://www.bls.gov/ooh/healthcare/nursing-assistants.htm ↵
9. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Nursing Assistants and Orderlies.
https://www.bls.gov/ooh/healthcare/nursing-assistants.htm ↵
10. Miller-Hoover, S. (2018). I said what? Professionalism for the CNA. RN.com.https://www.rn.com/featured-
stories/professionalism-cna/#:~:text=Professional%20CNAs%20are%20resp[/footnote] Professional behavior includes
communicating respectfully with clients, their family members, and other health care team members and introducing oneself
before beginning care. It also includes being a professional employee, such as performing hand hygiene, exhibiting good
personal hygiene and appearance, being dependable and on time for work, and completing one’s assigned tasks in an accurate
and timely manner. Professionalism includes understanding and working within one's scope of practice and being a lifelong
learner to continue to provide excellent care as the health care environment changes. “Demonstrating professionalism in the
workplace” is further discussed in Chapter 2.

Initiating and Concluding Personal Cares

When initiating care with a client, it is important to begin by introducing oneself. When initiating care with patients, it is
essential to first provide privacy and then introduce yourself and explain what will be occurring. Providing privacy means
taking actions such as talking with the patient privately in a room with the door shut. When concluding care, it is also important
to ask if the resident needs anything else, as well as ensuring safety measures are in place. These routine actions are further
discussed in “Pre- and Post-Procedural Steps” in Chapter 5. Before initiating care and after performing care, it is vital to
perform good hand hygiene. Using hand hygiene is a simple but effective way to prevent the spread of infection when
performed correctly and at the appropriate times. More details about using effective hand hygiene and preventing the spread of
infection are discussed in the “Precautions Used to Prevent the Spread of Infection” in Chapter 4.

Maintaining Good Hygiene and Personal Appearance

Managing your personal hygiene with good grooming habits is a component of professionalism that contributes to patient
satisfaction and prevents the spread of infection.[footnote]Miller-Hoover, S. (2018). I said what? Professionalism for the CNA. RN.com.
https://www.rn.com/featured-stories/professionalism-cna/#:~:text=Professional%20CNAs%20are%20resp ↵

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Licensing
A detailed breakdown of this resource's licensing can be found in Back Matter/Detailed Licensing.

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 CHAPTER OVERVIEW

1: Communicate Professionally Within a Health Care Setting

1.1: Introduction to Communicate Professionally Within A Health Care Setting
1.2: The Communication Process
1.3: Communication Within the Health Care Team
1.4: Human Needs and Developmental Stages
1.5: Documenting and Reporting
1.6: Learning Activities
1.7: I Glossary

This page titled 1: Communicate Professionally Within a Health Care Setting is shared under a CC BY 4.0 license and was authored, remixed,
and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

1
1.1: Introduction to Communicate Professionally Within A Health Care Setting
Learning Objectives
Interact professionally with clients, families, and coworkers
Display appropriate verbal and nonverbal communication skills in the health care setting
Establish therapeutic relationships with clients and their family members
Respond to clients exhibiting disruptive behaviors
Respond to aggressive behavior
Establish effective working relationships with supervisors and peers
Demonstrate effective reporting and documentation
Assist clients to meet spiritual needs
Adapt care and communication to meet the psychological needs of the aging client
Demonstrate empathy for the emotional needs and mental health of diverse clients
Apply effective coping strategies

Effective communication is a vital skill for nursing assistants. Nursing assistants communicate professionally with patients and
other health care team members throughout every shift. This chapter will review the communication process, discuss strategies for
adapting communication based on the needs of the client and health care team, and introduce guidelines for documentation and
reporting.

This page titled 1.1: Introduction to Communicate Professionally Within A Health Care Setting is shared under a CC BY 4.0 license and was
authored, remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts
platform; a detailed edit history is available upon request.

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1.2: The Communication Process
Communication is a process by which information is exchanged between individuals through a common system of symbols, signs,
[1]
or behavior. In the health care setting, good communication is the foundation to trusting relationships that improve client
outcomes. It is the gateway to providing holistic care. Holistic care addresses a client’s physical, emotional, social, and spiritual
[2] [3]
needs. The communication process involves a sender, the message, and a receiver. See Figure 1.1 for an illustration of the
communication process.

Figure 1.1 The Communication Process

Verbal Messages
There are many aspects of the communication process that can alter the delivery and interpretation of the message. These aspects
relate to the language and experience of both the sender and receiver, referred to as semantics. People typically make reference to
things they are familiar with, including landmarks, popular culture, and slang. Barriers can occur even when both parties in the
conversation speak the same language. For example, if you asked a person who has never used the Internet to “Google it,” they
would have no idea what that means.

Nonverbal Messages
Nonverbal messages, also referred to as body language, greatly impact the conversational process. Nonverbal communication
[4]
includes body language and facial expressions, tone of voice, and pace of the conversation. See Figure 1.2 for an illustration of
body language communicating a message. Nonverbal communication can have a tremendous impact on the communication
experience and may be much more powerful than the verbal message itself. You may have previously learned that 80% of
communication is nonverbal communication. The importance of nonverbal communication during conversation has been broken
[5]
down further, estimating that 55% of communication is body language, 38% is tone of voice, and 7% is the actual words spoken.
If the sender or receiver appears disinterested or distracted, the message or interpretation may become distorted or missed.

Figure 1.2 Body Language

Health care professionals assess receivers’ preferred methods of communication and individual characteristics that might influence
communication and then adapt communication to meet the receivers’ needs. For example, nursing assistants adapt verbal

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instructions for adult patients with cognitive disabilities. Although the information provided might be similar to that provided to a
patient without disabilities, the way the information is provided is adapted based on the patient’s developmental level. A nursing
assistant may ask a cognitively intact person, “What do you want for lunch?” but adapt this information for someone with impaired
cognitive function by offering a choice, such as “Do you want a sandwich or soup for lunch?” This adaptation allows the
[6]
cognitively impaired patient to make a choice without being confused or overwhelmed by too many options. Read more about
developmental levels in the “Human Needs and Developmental Stages” section of this chapter.

Communication Styles
In addition to using verbal and nonverbal communication, people communicate with others using one of three styles. A passive
communicator puts the rights of others before their own. Passive communicators tend to be apologetic or sound tentative when
they speak and often do not speak up if they feel as if they are being wronged. Aggressive communicators, on the other hand,
come across as advocating for their own rights despite possibly violating the rights of others when communicating. They tend to
communicate in a way that tells others their feelings don’t matter. Assertive communicators respect the rights of others while also
[7]
standing up for their own ideas and rights when communicating. An assertive person is direct, but not insulting or offensive.
Assertive communication refers to a way of conveying information that describes the facts and the sender’s feelings without
disrespecting the receiver’s feelings. Assertive communication is different from aggressive communication because it uses “I”
messages, such as “I feel…,” “I understand…,” or “Help me to understand…,” to address issues instead of using “you” messages
that can cause the receiver to feel as though they are being verbally attacked. Using assertive communication is an effective way to
solve problems with patients, coworkers, and health care team members. For example, instead of using aggressive communication
to say to a coworker, “You always leave your patients’ rooms a mess! I dread following you on the next shift,” an assertive
communicator would use “I” messages. The assertive communicator might say, “I feel frustrated spending the first part of my shift
decluttering patients’ rooms. Help me understand the reasons why you don’t empty the wastebaskets and clean up the rooms by the
[8]
end of your shift.”

Overcoming Communication Barriers

It is important to reflect on personal factors that influence your ability to communicate with others effectively. There are many
factors that can distort the message you are trying to communicate, resulting in your message not being perceived by the receiver in
[9]
the way you intended. When communicating, it is important to seek feedback that your message is clearly understood. Nursing
assistants must be aware of these potential barriers and try to reduce their impact by continually seeking feedback and checking
understanding. Review common communication barriers in the following box.

 Common Barriers to Communication in Health Care [10]

Jargon: Avoid using medical terminology, complicated wording, or unfamiliar words. When communicating with patients,
explain information in common language that is easy to understand. Consider any generational, geographical, or
background information that may change the perception or understanding of your message.
Lack of attention: It is easy to become task-centered rather than person-centered when caring for multiple residents. When
entering a patient’s room, remember to use preprocedural steps and mindfully focus on the person in front of you to give
them your full attention. Patients should feel as if they are the center of your attention when you are with them, no matter
how many other things you have going on.
Noise and other distractions: Health care environments can be very noisy with people talking in the room or hallway, the
TV blaring, alarms beeping, and pages occurring overhead. Create a calm, quiet environment when communicating with
patients by closing doors to the hallway, reducing the volume of the TV, or moving to a quieter area, if possible.
Light: A room that is too dark or too light can create communication barriers. Ensure the lighting is appropriate according
to the patient’s preference.
Hearing and speech problems: If your patient has hearing or speech problems, implement strategies to enhance
communication, including assistive devices such as eyeglasses, hearing aids, and any communication aids such as
whiteboards, photobooks, or microphones.
Language differences: If English is not your patient’s primary language, it is important to seek a medical interpreter and
provide written handouts in the patient’s preferred language when possible. Most agencies have access to an interpreter
service available by phone if they are not available on-site.

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 Differences in cultural beliefs: The norms of social interaction vary greatly in different cultures, as well as the ways that
emotions are expressed. For example, the concept of personal space varies among people from different cultural
backgrounds. Some people prefer to stand very close to one another when speaking whereas others prefer a distance of a
few feet. Additionally, some patients are stoic about pain whereas others are more verbally expressive when in pain.
Psychological barriers: Psychological states of the sender and the receiver affect how the message is sent, received, and
perceived. Consider what the receiver may be experiencing in the health care setting and what may change your delivery of
your message. Being rushed, distracted, and overwhelmed are just a few things that can affect your message and its
understanding.
Physiological barriers: It is important to be aware of patients’ potential physiological barriers when communicating. For
example, if a patient is in pain, they are less likely to hear and remember what was said. If the patient is receiving pain
medication, be aware these medications may alter their comprehension and response.
Physical barriers for nonverbal communication: Providing information via email or text is often less effective than face-
to-face communication. The inability to view the nonverbal communication associated with a message, such as tone of
voice, facial expressions, and general body language, often causes misinterpretation of the message by the receiver. When
possible, it is best to deliver important information to others using face-to-face communication so that nonverbal
communication is included with the message.
Differences in perceptions and viewpoints: Everyone has their own beliefs and perspectives and wants to feel “heard.”
When patients feel their beliefs or perspectives are not valued, they often become disengaged from the conversation or their
plan of care. Information should be provided in a nonjudgmental manner, even if the patient’s perspectives, viewpoints, and
beliefs are different from your own.

1. Merriam-Webster. Communication. https://www.merriam-webster.com/dictionary/communication ↵

2. Jasemi, M., Valizadeh, L., Zamanzadeh, V., & Keogh, B. (2017). A concept analysis of holistic care by hybrid model. Indian
Journal of Palliative Care, 23(1), 71–80. https://doi.org/10.4103/0973-1075.197960 ↵
3. “Communication Process” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
4. “Boulder_Worldcup_Vienna_29-05-2010a_semifinals090_Akiyo_Noguchi,_Anna_Stöhr.jpg” by Manfred Werner - Tsui is
licensed under CC BY-SA 3.0 ↵
5. Thompson, J. (2011). Is nonverbal communication a numbers game? Psychology Today.
https://www.psychologytoday.com/us/blog/beyond-words/201109/is-nonverbal-communication-numbers-game ↵
6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
7. This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0 ↵
8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
10. SkillsYouNeed. (n.d.). Barriers to effective communication. https://www.skillsyouneed.com/ips/barriers-communication.html ↵

This page titled 1.2: The Communication Process is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra
Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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1.3: Communication Within the Health Care Team
Communicating With Staff
The resident is at the center of the health care team. As a nursing assistant, most of your duties will involve interaction regarding
nursing services among other CNAs, LPNs, and RNs. It is important to establish a good relationship with coworkers to ensure
quality resident care. Improper communication can affect the team’s ability to provide holistic care. The health care team will be
discussed further in Chapter 2.
Good communication starts by respecting those you work with and using the communication skills previously discussed to grow a
trusting relationship. Knowing and fulfilling your duties, documenting and reporting the completion of these duties, and
functioning in a consistent and dependable manner are keys to creating strong, professional relationships within your team.
These expectations for good communication may seem challenging as an inexperienced nursing assistant, but they can be achieved
by organizing your responsibilities and managing your time. This begins by arriving on time for your shift, being dressed
appropriately, being prepared to start working when your shift starts, and reviewing your assigned residents’ plans of care at the
beginning of the shift. Items to review in the plan of care include the following:
Resident’s name and location
Activity level and transfer status
Assistance required for activities of daily living (ADLs)
Diet and fluid orders (see Chapter 6 for more information)
Elimination needs
Transfer status refers to the assistance the patient requires to be moved from one location to another, such as from the bed to a
chair. Activities of daily living (ADLs) are daily basic tasks that are fundamental to everyday functioning (e.g., hygiene,
elimination, dressing, eating, ambulating/moving). Diet and fluid orders refer to what the resident is permitted to eat and drink.
Elimination needs refer to assistance the resident requires for urinating and passing stool. For example, a resident requires
assistance to the toilet and uses incontinence pads.
After reviewing the cares you will be providing to your assigned patients during your shift, discuss a timeline with your coworkers
that meets residents’ schedules and allows for the coordination of cares that require more than one caregiver. For example, one
resident may require a two-person assist when transferring from the bed to the chair. Schedules for activities, treatments, labs,
appointments, or other services should also be reviewed so that cares can be organized around these schedules.
As resident cares are completed, they must be documented in a timely manner and reported to nursing staff. Prepare a concise
report to share with the nurse for each of your assigned clients. The report should include the time cares were provided and any
observations or changes noted in the resident. Read more about documentation and reporting in the “Documenting and Reporting”
section at the end of this chapter.

Communicating With the Client, Families, and Loved Ones

Therapeutic communication is a type of professional communication used with patients. It is defined as the purposeful,
interpersonal, information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills
[1]
that leads to patient understanding and participation. Therapeutic communication techniques have been used by nurses since
Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She believed in the
[2]
therapeutic healing that results from nurses’ presence with patients. Since then, several professional nursing associations have
[3]
highlighted therapeutic communication as one of the most vital elements in nursing. Nursing assistants also implement
therapeutic communication with patients. Read an example of a nursing student effectively using therapeutic communication with
patients in the following box.

 An Example of Nursing Student Using Therapeutic Communication [4],[5]

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 Figure 1.3 Attending Behaviors
Ms. Z. is a nursing student who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and
introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She
does her best to solve their problems and answer their questions. Patients perceive that she wants to help them. She treats
patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses
communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand
her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable
sharing their health care needs with her.

There are several components included in therapeutic communication. The health care professional uses active listening and
attending behaviors to demonstrate they are interested in understanding what the patient is saying. Touch is used to professionally
communicate caring, and specific therapeutic techniques are used to encourage the patient to share their thoughts, concerns, and
feelings.

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. A well-known phrase from a Greek philosopher named Epictetus is,
“We have two ears and one mouth so we can listen twice as much as we speak.” It is important to actively listen to patients and not
use competitive or passive listening. Competitive listening occurs when we are primarily focused on sharing our own point of
view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person or we
assume we correctly understand what the person is communicating without verifying their message. During active listening, we
communicate verbally and nonverbally that we are interested in what the other person is saying and also verify our understanding
with the speaker. For example, an active listening technique is to restate what the person said and verify our understanding is
correct, such as, “I hear you saying you are hesitant to go to physical therapy because you are afraid of falling. Is that correct?”
[6]
This feedback process is the main difference between passive listening and active listening.

Touch
Touch is a powerful way to professionally communicate caring and compassion if done respectfully while being aware of the
patient’s cultural beliefs. NAs commonly use professional touch when assessing, expressing concern, or comforting patients. For
[7]
example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 1.4
for an image of a nurse using touch as a therapeutic technique when caring for a patient.

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 Figure 1.4 Using Touch as a Therapeutic Technique

Therapeutic Communication Techniques

Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing
on their concerns. Nursing assistants help patients complete activities of daily living and meet goals in their plan of care based on
their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions,
maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the
patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic
communication, health care professionals often ask open-ended questions, repeat information, or use silence to prompt patients to
process their concerns. Table 1.3a describes a variety of therapeutic communication techniques.
[8]
Table 1.3a Therapeutic Communication Techniques

Therapeutic Technique Description

By using nonverbal and verbal cues such as nodding and saying, “I

see,” health care professionals can encourage patients to continue
talking. Active listening involves showing interest in what patients have
c… Active Listening to say, acknowledging that you’re listening and understanding, and
engaging with them throughout the conversation. General leads such as
“What happened next?” can be used to guide the conversation or propel
it forward.
At times, it’s useful to not speak at all. Deliberate silence can give
patients an opportunity to think through and process what comes next in
c… Using Silence
the conversation. It may also give them the time and space they need to
broach a new topic.
Sometimes it is important to acknowledge a patient’s message and
affirm they’ve been heard. Acceptance isn’t necessarily the same thing
as agreement; it can be enough to simply make eye contact and say, “I
c… Providing Acceptance
hear what you are saying.” Patients who feel their health care
professionals are listening to them and taking them seriously are more
likely to be receptive to care.
Recognition acknowledges a patient’s behavior and highlights it. For
c… Giving Recognition example, saying something such as “I noticed you ate all of your
breakfast today” draws attention to the action and encourages it.
Hospital stays can be lonely and stressful at times. When health care
professionals make time to be present with their patients, it
c… Offering Self communicates they value them and are willing to give them time and
attention. Offering to simply sit with patients for a few minutes is a
powerful way to create a caring connection.

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 Therapeutic communication is often most effective when patients direct
the flow of conversation and decide what to talk about. For example,
c… Giving Broad Openings/Open-Ended Questions giving patients a broad opening such as “What’s on your mind today?”
or “What would you like to talk about?” is a good way to allow patients
an opportunity to discuss what’s on their mind.
Similar to active listening, asking patients for clarification when they
say something confusing or ambiguous is important. Saying something
c… Seeking Clarification such as “I’m not sure I understand. Can you explain more to me?” helps
health care professionals ensure they understand what’s actually being
said and can help patients process their ideas more thoroughly.
Asking questions about when certain events occurred in relation to other
events can help patients (and health care professionals) get a clearer
c… Placing the Event in Time or Sequence sense of the whole picture. It forces patients to think about the sequence
of events and may prompt them to remember something they otherwise
wouldn’t.
Making observations about the appearance, demeanor, or behavior of
patients can help draw attention to areas that may indicate a problem.
c… Making Observations
For example, making an observation that they haven’t been eating much
may lead to the discovery of a new symptom.
For patients experiencing sensory issues or hallucinations, it can be
helpful to ask about these perceptions in an encouraging, nonjudgmental
c… Encouraging Descriptions of Perception way. Phrases such as “What do you hear now?” or “What do you see?”
give patients a prompt to explain what they’re perceiving without
casting their perceptions in a negative light.
Patients often draw upon previous experiences to deal with current
problems. By encouraging them to make comparisons to situations they
c… Encouraging Comparisons
have coped with before, health care professionals can help patients
discover solutions to their problems.
It is often useful to summarize what patients have said. This
demonstrates you are listening and allows you to verify information.
c… Summarizing Ending a summary with a phrase such as “Does that sound correct?”
gives patients explicit permission to make corrections if they’re
necessary.
Patients often ask health care professionals for advice about what they
should do about particular problems. Instead of offering advice, health
c… Reflecting care professionals can ask patients to reflect on what they think they
should do, which encourages them to be accountable for their own
actions and helps them come up with solutions themselves.
Sometimes during a conversation, patients mention something
particularly important. When this happens, health care professionals can
focus on this statement and prompt patients to discuss it further. Patients
c… Focusing
don’t always have an objective perspective on what is relevant to their
case, but as impartial observers, health care professionals may be able
to pick out the topics on which to focus.
Health care professionals should only use this technique after they have
established trust and rapport with the client. In some situations, it can be
vital to disagree with patients, present them with reality, or challenge
c… Confronting
their assumptions. Confrontation, when used correctly, can help patients
break destructive routines or understand the state of their current
situation.
Voicing doubt can be a gentler way to call attention to incorrect or
delusional ideas and perceptions of patients when appropriate. For
c… Voicing Doubt example, when appropriate, a health care worker may say to a patient
experiencing visual hallucinations, “I know you said you are seeing
spiders on the walls, but I don’t see any spiders.”

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 Because hospitals can be stressful places for patients, sharing hope that
they can persevere through their current situation or lightening the
c… Offering Hope and Humor mood with humor can quickly establish rapport. This technique can help
move patients in a more positive state of mind. However, it is important
to tailor humor to the patient’s sense of humor.

In addition to the therapeutic techniques listed in Table 1.3a, health care professionals should genuinely communicate with patients
with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to establishing true connections
[9]
with others. Communicating with empathy can be described as providing “unconditional positive regard.” Research has
demonstrated that when health care professionals communicate with empathy, there is improved patient healing, reduced symptoms
[10]
of depression, and decreased medical errors.

Nontherapeutic Responses
Health care professionals must be aware of potential barriers to communication. In addition to the common communication barriers
discussed in the “Communication Styles” subsection of this chapter, there are several nontherapeutic responses to avoid. These
nontherapeutic responses often block the patient’s communication of their feelings or ideas. See Table 1.3b for a description of
[11]
nontherapeutic responses.
[12]
Table 1.3b Nontherapeutic Responses

Nontherapeutic Response Description

Asking personal questions that are not relevant to the situation is not
professional or appropriate. Don’t ask questions just to satisfy your
c… Asking Personal Questions curiosity. For example, asking, “Why have you and Mary never
married?” is not appropriate. A more therapeutic question would be,
“How would you describe your relationship with Mary?”
Giving personal opinions takes away the decision-making from the
patient. Effective problem-solving must be accomplished by the patient
c… Giving Personal Opinions and not the NA. For example, stating, “If I were you, I’d put your father
in a nursing home” is not therapeutic. Instead, it is more therapeutic to
say, “Let’s talk about what options are available to your father.”
Changing the subject when someone is trying to communicate with you
demonstrates lack of empathy and blocks further communication. It
seems to say that you don’t care about what they are sharing. For
c… Changing the Subject example, stating, “Let’s not talk about your insurance problems; it’s
time for your walk now” is not therapeutic. A more therapeutic response
would be, “After your walk, let’s talk more about your concerns about
insurance so I can help find assistance for you.”
Generalizations and stereotypes can threaten relationships with patients.
For example, it is not therapeutic to state a stereotype like, “Older adults
c… Stating Generalizations and Stereotypes
are always confused.” It is better to focus on the patient’s concern and
ask, “Tell me more about your concerns about your wife’s confusion.”
When a patient is seriously ill or distressed, it is tempting to offer false
hope with statements such as “You’ll be fine,” or “Don’t worry;
everything will be alright.” These comments tend to discourage further
c… Providing False Reassurances
expressions of feelings by the patient. A more therapeutic response
would be, “It must be difficult not to know what the surgeon will find.
What can I do to help?”
Sympathy focuses on the health care professional’s feelings rather than
the patient. Saying “I’m so sorry about your amputation; I can’t imagine
c… Showing Sympathy losing a leg” shows pity rather than trying to help the patient cope with
the situation. A more therapeutic response would be, “The loss of your
leg is a major change; how do you think this will affect your life?”

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 It can be tempting to ask a patient to explain “why” they believe, feel,
or act in a certain way. However, patients and family members can
interpret “why” questions as accusations and become defensive. It is
c… Asking “Why” Questions
best to phrase a question by avoiding the word “why.” For example,
instead of asking, “Why are you so upset?” it is better to rephrase the
statement as, “You seem upset. What’s on your mind?”
Health care professionals should not impose their own attitudes, values,
beliefs, and moral standards on patients or family members. Judgmental
messages contain terms such as “should,” “shouldn’t,” “ought to,”
“good,” “bad,” “right,” or “wrong.” Agreeing or disagreeing sends the
subtle message that health care professionals have the right to make
value judgments about the patient’s decisions. Approving implies that
the behavior being praised is the only acceptable one, and disapproving
c… Approving or Disapproving implies that the patient must meet the listener’s expectations or
standards. Instead, health care professionals should help the patient
explore their own beliefs and decisions. For example, it is
nontherapeutic to state, “You shouldn’t schedule elective surgery; there
are too many risks involved.” A more therapeutic response would be,
“So you are considering elective surgery. Tell me more about it…” This
response gives the patient a chance to express their ideas or feelings
without fear of being judged.
When patients or family members express criticism, health care
professionals should actively listen. Listening does not imply
agreement. To discover reasons for the patient’s anger or dissatisfaction,
health care professionals should listen without criticism, avoid being
defensive or accusatory, and attempt to defuse anger. For example, it is
c… Giving Defensive Responses not therapeutic to state, “No one here would intentionally lie to you.”
Instead, a more therapeutic response would be, “You believe people
have been dishonest with you. Tell me more about what happened.”
(After obtaining additional information, the health care worker may
decide to follow the chain of command at the agency and report the
patient’s concerns to the nurse supervisor for follow-up.)
Passive responses serve to avoid conflict or sidestep issues, whereas
c… Providing Passive or Aggressive Responses aggressive responses provoke confrontation. Health care workers should
use assertive communication.
Challenging or arguing against patient perceptions denies that they are
real and valid to the other person. They imply that the other person is
lying, misinformed, or uneducated. The skillful health care professional
can provide alternative information or present reality in a way that
c… Arguing avoids argument. For example, it is not therapeutic to state, “How can
you say you didn’t sleep a wink when I heard you snoring all night
long!” A more therapeutic response would be, “You don’t feel rested
this morning? Let’s talk about ways to improve your sleep so you feel
more rested.”

Strategies for Effective Communication

In addition to overcoming common communication barriers, using active listening and therapeutic communication techniques, and
avoiding nontherapeutic responses, there are additional strategies for promoting effective communication when providing patient-
[13]
centered care. Specific questions to ask patients are as follows :
What concerns do you have about your plan of care?
What questions do you have about your daily routine?
Did I answer your question(s) clearly, or is there additional information you would like?
Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-
care experience, and provide high-quality care. Other suggestions for effective communication with clients include the following:

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 Read the care plan carefully and access any social history available. If family members or friends visit and it seems appropriate,
talk with them about the client without intruding or taking up a lot of their time together. This information helps you build trust
and care for the client based on their preferences and life history. For example, you might learn the resident lived on a farm
most of their life and enjoyed taking care of their horses. Striking up conversations about horses is a way to build rapport with
this client.
Review any changes in routine or in the plan of care for assisting with ADLs with the client to improve understanding and
participation.
If there are questions you can’t answer, be sure to report to the nurse so someone can follow up with the client. Check back with
the client to ensure they have had their questions answered.
Observe nonverbal communication from clients. Do they seem to interact during care, or is it something that they are merely
tolerating and just trying to get through each day? Find an approach so they are comfortable with receiving care.

Adapting Your Communication

When communicating with patients, their family members, and other caregivers, note your audience and adapt your message based
on characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with
language differences, it is vital to provide trained medical interpreters when important information is communicated.
[14]
Adapting communication according to an individual’s age and developmental level includes the following strategies :
When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a
procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
When communicating with adolescents, give freedom to make choices within established limits.
When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address
these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before
communicating.

Strategies for Communicating With Patients With Impaired Hearing, Vision, and Speech
In addition to adapting your communication to your audience, there are additional strategies to use with individuals who have
impaired hearing, vision, or speech.
[15]
Impaired Hearing
Gain the person’s attention before speaking (e.g., through touch)
Minimize background noise
Position yourself 2-3 feet away from the patient
Facilitate lip-reading by facing the person directly in a well-lit environment
Use gestures, when necessary
Listen attentively, allowing the person adequate time to process communication and respond
Refrain from shouting at the person
Ask the person to suggest strategies for improved communication (e.g., speaking toward a better ear, moving to well-lit area,
and speaking in a lower-pitched tone)
Face the person directly, establish eye contact, and avoid turning away mid-sentence
Simplify language (e.g., do not use slang but do use short, simple sentences), as appropriate
Read the care plan for information on the preferred method of communicating (whiteboards, pictures, etc.)
Assist the person using any devices such as hearing aids or voice amplifiers
Report any changes to the nurse
[16]
Impaired Vision
Identify yourself when entering the person’s space
Ensure the patient’s eyeglasses are cleaned and stored properly when not in use, and assist the patient in wearing them during
waking hours
Provide adequate room lighting
Minimize glare (e.g., offer sunglasses, draw window covering, position with face away from window)
Provide educational materials in large print as available
Read pertinent information to the patient

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 Provide magnifying devices
Report any changes to the nurse
[17]
Impaired Speech
Some patients may have problems processing what they are hearing or in responding to questions due to dementia, brain injuries, or
prior strokes. This difficulty is referred to as aphasia. There are different types of aphasia. People with expressive aphasia
understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For
example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed.
People with receptive aphasia often speak in long sentences, but what they say may not make sense. They are unable to understand
both verbal and written language. Aphasia often causes the person to become frustrated when they cannot communicate their needs.
[18]
Review the following evidence-based strategies to enhance communication with a person with impaired speech :
Modify the environment to minimize excess noise and decrease emotional distress
Phrase questions so the patient can answer using a simple “Yes” or “No,” being aware that patients with expressive aphasia may
provide automatic responses that are incorrect
Monitor the patient for frustration, anger, depression, or other responses to impaired speech capabilities
Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with
pictures and letters, hand signals or gestures, or computer)
Adjust your communication style to meet the needs of the patient (e.g., stand in front of the patient while speaking, listen
attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written communication, or solicit the
family’s assistance in understanding the patient’s speech)
Ensure the call light is within reach
Repeat what the client said to ensure accuracy
Instruct the client to speak slowly
Read the care plan for instructions from the speech therapist
Report any changes to the nurse

Responding to Challenging Situations

Being a care provider is a very rewarding career, but it also includes dealing with challenging situations. Using strong
communication techniques can de-escalate situations and put patients, loved ones, and staff at ease. It is impossible to predict what
behavior you may encounter as a health care worker, but having a solid basis of communication techniques can prepare you to
better handle unique situations.

Memory Impairment and Behavioral Health Issues

As a nursing assistant, you will likely encounter older adults with varying degrees of memory impairment. Older adults are
[19]
defined as adults aged 65 years old or older. Residents with memory issues often become confused and can feel overwhelmed by
everyday situations. For those with impaired cognitive functioning like dementia, it may not be possible to reorient them to the
current time and place or to move them on from thoughts that are not based in the current situation. Aphasia and confusion can
cause frustration that can result in agitation or aggression. Agitation refers to behaviors that fall along a continuum ranging from
verbal threats and motor restlessness to harmful aggressive and destructive behaviors. Mild agitation includes symptoms such as
irritability, oppositional behavior, inappropriate language, and pacing. Severely agitated patients are at immediate risk of harming
[20]
themselves or others through assaultive or self-injurious behavior, and they are capable of causing property damage. Aggression
[21]
is an act of attacking without provocation. Agitation and aggression will be discussed in more detail in Chapter 10, but general
guidelines to prevent aggression and agitation include the following:
Keep the environment calm and as quiet as possible.
Build trusting relationships by learning resident preferences and routines.
Gather information from family members and loved ones about the patient’s background and beliefs.
Offer choices to allow the patient to communicate preferences, but do not cause them to be overwhelmed with too many
decisions.
Stick to a daily routine for ADLs, meals, and activities.
Empathize with the resident and understand that challenging behavior is often communication of emotion due to cognitive
impairment and not a choice.

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 Practice validation therapy. Validation therapy is a method of therapeutic communication used to connect with someone who
has moderate- to late-stage dementia and avoid agitation. It places more emphasis on the emotional aspect of a conversation and
less on the factual content, thereby imparting respect to the person, their feelings, and their beliefs. Validation may require you
to agree with a statement that has been made, even though the statement is neither true or real, because to the person with
[22]
dementia, it feels both true and real. For example, if the resident with dementia believes they are waiting to catch the bus and
is intent on doing so, sit with them by the window as if you are waiting for a bus and continue to have interaction with them
until they are no longer concerned with the bus.
Redirect behavior if appropriate. For example, suggest alternative activities such as walking around the facility, looking at
photos, listening to music, or other activities the resident enjoys.
Focus on safety for residents experiencing delusions or hallucinations. Delusions are unshakable beliefs in something that isn’t
true or based on reality. For example, a resident may refuse to eat breakfast because they have a delusion that staff are trying to
poison them. Hallucinations are sensing things such as visions, sounds, or smells that seem real but are not. For example, a
resident may refuse to enter a room because they have hallucinations of big spiders crawling on the walls. If a patient is having
delusions or hallucinations, never contradict them or tell them what they perceive isn’t real. Instead, empathize with them and
do whatever is possible to help them feel safe. For example, offer to move to another area or investigate what the resident is
concerned about.

Dealing With Stress

The stress response is a common psychological barrier to effective communication. It can affect the message sent by the sender or
the reception by the receiver. The stress response is a common reaction to life events, such as a health care worker feeling
overwhelmed with tasks to complete for multiple patients or a patient feeling stressed when admitted to a hospital or receiving a
new diagnosis. Symptoms of the stress response include irritability, sweaty palms, a racing heart, difficulty concentrating, and
impaired sleep. It is important to recognize symptoms of the stress response in ourselves and our patients and use strategies to
manage the stress response when communicating.
[23]
There are several stress management strategies to use to manage the stress response :
Use relaxation breathing to become aware of one’s breathing. This technique includes taking deep breaths in through the nose
and blowing it out through the mouth. This process is repeated at least three times in succession and then as often as needed
throughout the day.
Make healthy diet choices. Avoid caffeine, nicotine, and junk food because these items can increase feelings of anxiety or being
on edge.
Make time for exercise. Exercise stimulates the release of natural endorphins that reduce the body’s stress response and also
helps to improve sleep.
Get enough sleep. Set aside at least 30 minutes before going to bed to wind down from the busyness of the day. Avoid using
electronic devices like cell phones before bedtime because the backlight can affect sleep.
Use progressive relaxation. There are several types of progressive relaxation techniques that focus on reducing muscle tension
and using mental imagery to induce calmness. Progressive relaxation generally includes the following steps:
Start by lying down somewhere comfortable and firm, like a rug or mat on the floor. Get yourself comfortable.
Relax and try to let your mind go blank. Breathe slowly, deeply, and comfortably, while gradually and consciously relaxing
all your muscles, one by one.
Work around the body one main muscle area at a time, breathing deeply, calmly, and evenly. For each muscle group, clench
the muscles tightly and hold for a few seconds, and then relax them completely. Repeat the process, noticing how it feels.
Do this for each of your feet, calves, thighs, buttocks, stomach, arms, hands, shoulders, and face.

Managing Clients’ and Family Members’ Stress

Being cared for by strangers can feel very challenging to clients. Residents in long-term care settings have frequently experienced
major physical and/or cognitive changes that caused a loss of their independence and sometimes some of their autonomy.
Autonomy is each individual’s right to self-determination and decision-making based on their unique values, beliefs, and
preferences. It is important for the nursing assistant to empathize with these losses and the new reality that residents must become
accustomed to when moving into a long-term care facility. Reflect on the exercise in the following box to understand a resident’s
feelings during their transition:

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  Reflection Activity

When you wake up in the morning, imagine that you cannot get out of bed on your own. Think about putting on your call light
as you need to use the restroom and having to wait until someone is available to help. As you look around the room, you see
some of your belongings, but many are no longer there. The floor is clean but bare; your recliner is nearby but you can’t move
into it. You wish you could go to the kitchen to have coffee with your partner, but they are no longer around. You miss your pet
that used to sleep with you each night. Finally, an aide arrives, and although they are friendly, it is another new face that will
help you to the bathroom and with other care needs.

Clients usually become more comfortable with their new reality as they become familiar with a new routine and their new home. It
is important to remember that emotions related to loneliness, feeling like a burden, and loss of independence can arise at any time.
The nursing assistant can help residents adjust to their new environment in the following ways:
Greet clients by their preferred name and introduce yourself.
Ask clients their preferences for their care. Always communicate what you will be doing next and allow the resident to redirect
or refuse care.
Provide privacy when assisting with cares.
Use confidentiality when documenting information or reporting to other members of the health care team.
Treat belongings carefully and with respect and remember the client’s room is their home.
Listen to the resident and address concerns if they arise. If you cannot adequately address the resident’s concerns, communicate
these concerns to the nurse or supervisor.
Family members and other loved ones may have questions and concerns about the resident’s care. Read more information about
managing their concerns in the following “Dealing With Conflict” section.

Dealing With Conflict

Health care professionals provide personal care at integral times in the lives of patients. The demands of caregiving and the
associated rapid decision-making process can create stress for health care team members, patients, family members, and other
loved ones. Managing care and making decisions can cause conflict among all involved. As a nursing assistant, it is important to be
aware of your role and responsibility when managing conflict.
When a patient does not want to participate in care necessary to support their proper hygiene or health maintenance, the nursing
assistant can use effective communication to encourage actions and promote desired outcomes. When a resident declines care, here
are some actions the nursing assistant may use that respect their choices but allow care standards to be met:
Re-approach the resident at a later time.
Offer an alternative method. For example, a resident may not want to shower or take a bath but would be willing to have a full
bed bath, allowing them to stay covered and warm throughout care.
Remind the resident what may occur if care is not provided, such as higher risk of infection, open areas in the skin, odor, etc.
Encourage as much control and independence as possible. Allow the resident to direct the process if able and offer as many
choices as are appropriate.
Family members and other supports may have concerns about the plan of care for a resident. This may be due to lack of medical
knowledge, little experience with the procedures of health care facilities, or a feeling of helplessness in regard to their loved one’s
situation. The nursing assistant should listen to and acknowledge these concerns. Following confidentiality guidelines,
interventions included in the plan of care can be discussed if the resident has permitted disclosure of this information. However, the
nursing assistant should only disclose information when they have confirmed the resident has permitted disclosure. It may be
beneficial for family members or others involved to discuss concerns with the nurse or unit supervisor and possibly schedule a care
conference with the health care team to resolve their concerns. In this instance, the aide should understand that any anger directed
at them may be a result of the situation rather than a reflection of anything they have personally done.
Conflicts among coworkers can also be addressed with assertive communication techniques. As discussed in the “Communication
Styles” subsection, using assertive communication is the best approach to address workplace conflict and a respectful way to make
one’s viewpoints known. Communication should start between the two parties that have the conflict before involving other staff. It
is best to think about the situation and develop a potential solution before approaching the coworker. Frame the situation from your
perspective using “I” messages. If the situation is especially tense, it may be beneficial to allow some time between the experience

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and the discussion to reduce stress and think more logically about the conflict. A typical time frame is to wait one day to think
logically about a conflict before addressing it, often referred to as the “24-hour Rule.” If you have discussed your concerns with the
coworker and offered a potential solution without any resolution in the situation, it is appropriate to notify your supervisor for
additional assistance at that time. See an example of conflict resolution in the following box.

 Example of Conflict Resolution

A nursing assistant becomes frustrated with a coworker who works on the previous shift when they continue to neglect to
empty the wastebaskets and tidy up the residents’ rooms before the end of their shift. When it became apparent this was a
pattern of behavior and not an isolated incident due to an exceedingly busy shift, the nursing assistant approached the coworker
and said, “I feel frustrated when I start my shift with full wastebaskets and untidy rooms for the residents you care for. Can you
help me understand why these things aren’t accomplished by the end of your shift? It works for me to clean up the room when
I am finished assisting the resident. That way I don’t forget to come back, and the residents seem to appreciate it as well.” The
coworker apologized for this oversight and committed to completing these tasks before leaving at the end of their shift.

1. Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing
students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968 ↵
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States of America MC2 John O'Neill Herrera/U.S. Navy is licensed in the Public Domain ↵
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https://www.apa.org/topics/stress/tips ↵

This page titled 1.3: Communication Within the Health Care Team is shared under a CC BY 4.0 license and was authored, remixed, and/or
curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history
is available upon request.

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1.4: Human Needs and Developmental Stages
It is important to understand human needs and developmental stages to communicate effectively and provide holistic care.

Maslow’s Hierarchy of Needs

Maslow’s Hierarchy of Needs was created in 1943 by American psychologist Abraham Maslow. Maslow’s theory is based on the
ranking of the importance of human needs and the belief that human actions are based on motivation to meet these needs. See an
[1]
illustration of Maslow’s Hierarchy of Needs in Figure 1.5.

Figure 1.5 Maslow’s Hierarchy of Needs

Maslow’s theory states that unless the basic needs in the lower levels of the hierarchy are met, humans cannot experience the higher
[2]
levels of psychological and self-fulfillment needs. The levels of Maslow’s Hierarchy of Needs have the following definitions :
1. Physiological needs: This is the most important level with basic needs humans must have to stay alive and function, including
air, food, drink, shelter, clothing, warmth, sex, and sleep.
2. Safety needs: People want to experience order, predictability, and control in their lives. This includes emotional security,
freedom from fear, and health and well-being (such as safety against falls and injury). For new residents in a long-term care
facility, this level includes becoming comfortable in familiar surroundings as opposed to feeling apprehension when
experiencing a new environment.
3. Love and belongingness: After physiological and safety needs have been fulfilled, the third level of human needs is social and
involves feelings of belongingness. Belongingness refers to a human emotional need for interpersonal relationships,
connectedness, and being part of a group. A group may mean biological families, friends, or other supporters. It may also
include physical intimacy and romantic relationships.
4. Esteem needs: Esteem needs include self-worth and feelings of accomplishment and respect. It includes how one views oneself
and the feeling of contributing to something of importance.
5. Self-actualization: Self-actualization is the highest level and refers to the realization of a person’s potential and self-fulfillment.
This level refers to the desire to attain life goals and being truly satisfied in being the most one can be.
Maslow theorized that one cannot attain a higher level in any of these categories if the levels below are not met. For example, one
is not motivated by a sense of belonging if they are focused on obtaining basic needs such as food, water, and shelter. The hierarchy
is subjective because each individual determines what each level means for them. For instance, for one person, safety may mean
living in the neighborhood where they grew up, whereas for another individual it means having a daily routine. Belongingness to
one person may mean being a part of a community group whereas to another it may mean having one very close friend. Self-esteem
and feelings of accomplishment may be defined by one person as successfully graduating from high school, whereas to another it is
defined by being able to run a mile without stopping. Self-actualization is defined by each individual and can mean things such as
being a good parent, graduating from college, or achieving one’s dream of becoming a nurse.
The levels of belongingness and self-actualization also include a person’s spirituality and how they find meaning and purpose in
life. Spirituality is often mistakenly equated with religion, but spirituality is a broader concept that includes how people seek
[3]
meaning and purpose in life, as well as establish relationships with family, their community, nature, and/or a higher power.

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Maslow’s Hierarchy of Needs is a good basis for providing holistic care and communicating with clients based on their needs and
preferences. For example, in nursing, priorities of care are based on physiological needs and safety. Additionally, knowing that a
newly admitted resident may have difficulty reaching a higher level of needs if their basic needs are not met is a good starting point
for providing care.
Strategies that integrate Maslow’s Hierarchy of Needs when providing care to residents include the following:
Following the nursing plan of care to meet physiological needs.
Implementing fall precautions to keep residents safe.
Answering call lights promptly and consistently providing a calm, comfortable environment to make residents feel secure.
Respecting residents’ belongings and asking their preferences for grooming, bathing, and meals to satisfy self-esteem needs.
Encouraging interaction among residents with similar interests to promote a feeling of belongingness.
Offering to bring residents to on-site religious activities or referring them to social services for a chaplain visit to promote self-
actualization and a feeling of belongingness.
Maslow’s Hierarchy of Needs can also be applied to the work environment to enhance professionalism by doing the following:
Offering assistance to coworkers when able to promote a feeling of security and belongingness and also maintaining residents’
physiological needs and safety as a team.
Participating fully in the reporting and documentation process of the facility to meet residents’ physiological and safety needs.
Accurately following training and agency policies and procedures to encourage feelings of self-esteem in the health care
worker.
Being accountable for one’s actions and job responsibilities to promote a feeling of self-actualization by meeting one’s
potential.

Erikson’s Stages of Development

Another psychologist named Erik Erikson created a theory of psychosocial development that also describes how one’s personality
is developed. It theorizes there are eight stages of development based on a person’s chronological age. Development occurs based
on the main conflict or challenge confronted during that period of time. Each stage can create either a virtue/strength or a
maladaptive tendency. Erikson proposed that those who have a stronger sense of identity from resolving these conflicts over time
[4]
have fewer conflicts within themselves and with others and, subsequently, a decreased level of anxiety.
Erikson’s stages of development are defined as trust versus mistrust, autonomy versus shame, initiative versus guilt, industry versus
inferiority, identity versus identity confusion, intimacy versus isolation, generativity versus stagnation, and integrity versus
[5]
despair :
Trust vs. Mistrust
The first stage establishes trust (or mistrust) that basic needs, such as nourishment and affection, will be met. Trust is the basis of
our development during infancy (birth to 12 months). Infants are dependent on their caregivers, so caregivers who are responsive
and sensitive to their infant’s needs help their baby to develop a sense of trust; their baby will see the world as a safe, predictable
place. Unresponsive caregivers who do not meet their baby’s needs can engender feelings of anxiety, fear, and mistrust; their baby
[6]
may see the world as unpredictable.
Autonomy vs. Shame
Toddlers begin to explore their world and learn that they can control their actions and act on the environment to get results. They
begin to show clear preferences for certain elements of the environment, such as food, toys, and clothing. A toddler’s main task is
to resolve the issue of autonomy versus shame and doubt by working to establish independence. For example, we might observe a
budding sense of autonomy in a two-year-old child who wants to choose her clothes and dress herself. Although her outfits might
not be appropriate for the situation, her input in such basic decisions has an effect on her sense of independence. If denied the
opportunity to act on her environment, she may begin to doubt her abilities, which could lead to low self-esteem and feelings of
[7]
shame.
Initiative vs. Guilt
Once children reach the preschool stage (ages 3–6 years), they are capable of initiating activities and asserting control over their
world through social interactions and play. By learning to plan and achieve goals while interacting with others, preschool children

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can master this task. Those who do will develop self-confidence and feel a sense of purpose. Those who are unsuccessful at this
[8]
stage may develop feelings of guilt.
Industry vs. Inferiority
During the elementary school stage (ages 7–11), children begin to compare themselves to their peers to see how they measure up.
They either develop a sense of pride and accomplishment in their schoolwork, sports, social activities, and family life, or they feel
[9]
inferior and inadequate when they don’t measure up.
Identity vs. Identity Confusion
In adolescence (ages 12–18), children develop a sense of self. Adolescents struggle with questions such as “Who am I?” and “What
do I want to do with my life?” Along the way, most adolescents try on many different selves to see which ones fit. Adolescents who
are successful at this stage have a strong sense of identity and are able to remain true to their beliefs and values in the face of
problems and other people’s perspectives. Teens who do not make a conscious search for identity or those who are pressured to
conform to their parents’ ideas for the future may have a weak sense of self and experience role confusion as they are unsure of
[10]
their identity and confused about the future.
Intimacy vs. Isolation
People in early adulthood (i.e., 20s through early 40s) are ready to share their lives with others after they have developed a sense of
self. Adults who do not develop a positive self-concept in adolescence may experience feelings of loneliness and emotional
[11]
isolation.
Generativity vs. Stagnation
When people reach their 40s, they enter a time period known as middle adulthood that extends to the mid-60s. The social task of
middle adulthood is generativity versus stagnation. Generativity involves finding your life’s work and contributing to the
development of others, through activities such as volunteering, mentoring, and raising children. Those who do not master this task
[12]
may experience stagnation, having little connection with others and little interest in productivity and self-improvement.
Integrity vs. Despair
The mid-60s to the end of life is a period of development known as late adulthood. People in late adulthood reflect on their lives
and feel either a sense of satisfaction or a sense of failure. People who feel proud of their accomplishments feel a sense of integrity
and often look back on their lives with few regrets. However, people who are not successful at this stage may feel as if their life has
been wasted. They focus on what “would have,” “should have,” or “could have” been. They face the end of their lives with feelings
[13]
of bitterness, depression, and despair.
By combining Maslow’s and Erickson’s theories of development and motivation, we can begin to understand why some patients
need more encouragement, space, or time to allow caregivers to provide assistance with their ADLs to maintain physical and
emotional health.

[14]
View the following YouTube video for more information about Erikson’s theory of development: Erikson’s Psychosocial
Development | Individuals and Society.

Assisting With Spiritual Needs

When clients experience a serious illness or injury, they often grapple with the existential question, “Why is this happening to me?”
This question can be a sign of spiritual distress defined as, “A state of suffering related to the inability to experience meaning in life
through connections with self, others, the world, or a superior being.” Spiritual well-being is a pattern of experiencing meaning and
purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself.
Spirituality is often mistakenly equated with religion, but spirituality is a broader concept. Elements of spirituality include faith,
[15]
meaning, love, belonging, forgiveness, and connectedness. Spirituality and religion can change over a person’s lifetime and vary
greatly between people. Some people who are very spiritual may not belong to a specific religion.
Religion is frequently defined as an institutionalized set of beliefs and practices. Many religions have specific rules about food,
religious rituals, clothing, and touching. Supporting these rules when they are meaningful part of a resident’s spirituality is an
effective way to support the resident and maintain a caring, professional relationship. The nursing assistant should discuss these

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aspects with the nurse to assure they support the plan of care for the resident and encourage other staff members to provide support.
Many nursing homes and assisted living facilities offer religious or spiritual opportunities through their Activities departments.
Many hospitals, nursing homes, assisted living facilities, and hospices employ professionally trained chaplains to assist with the
spiritual, religious, and emotional needs of clients, family members, and staff. In these settings, chaplains support and encourage
people of all religious faiths and cultures and customize their approach to each individual’s background, age, and medical
condition. Chaplains can meet with any individual regardless of their belief, or lack of belief, in a higher power and can be very
[16]
helpful in reducing anxiety and distress. NAs may suggest chaplain services for their clients.
An important way to assist a client with their spiritual well-being is to ask them what they need to feel supported in their faith and
then try to accommodate their requests, if possible. Explain that spiritual health helps the healing process. For example, perhaps
they would like to speak to their clergy, spend some quiet time in meditation or prayer without interruption, or go to the on-site
[17]
chapel. Many agencies have chaplains onsite that can be offered to patients as a spiritual resource.
If the client or family member requests a nursing assistant to pray with them, it is acceptable to pray with them or find someone
who will. Some nursing assistants may feel reluctant to pray with patients when they are asked for various reasons; they may feel
underprepared, uncomfortable, or unsure if they are “allowed to.” Nursing assistants, nurses, and other health care team members
are encouraged to pray with their patients to support their spiritual health, as long as the focus is on the patient’s preferences and
beliefs, not their own preferences. Having a short, simple prayer ready that is appropriate for any faith may help a health care
professional feel prepared for this situation. However, if the nursing assistant does not feel comfortable praying with the patient as
[18]
requested, the nurse should be notified so the chaplain can be requested to participate in prayer with the patient.
It is important to support clients within their own faith tradition, but it is not appropriate for the nursing assistant to take this
opportunity to attempt to persuade a patient towards a preferred religion or belief system. The role of the nursing assistant is to
[19]
respect and support the client’s values and beliefs, not promote the nursing assistant’s values and beliefs.

1. “Maslow%27s_Hierarchy_of_Needs2.svg” by Androidmarsexpress is licensed under CC.BY-SA 4.0 ↵

2. McLeod, S. (2020, March 20). Maslow’s hierarchy of needs. Simply Psychology.
https://www.simplypsychology.org/maslow.html ↵
3. Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014). Improving the spiritual dimension of whole person care: Reaching
national and international consensus. Journal of Palliative Medicine, 17(6), 642–656. https://doi.org/10.1089/jpm.2014.9427 ↵
4. This work is a derivative of StatPearls by Orenstein and Lewis and is licensed under CC BY 4.0 ↵
5. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
6. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
7. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
8. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
9. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
10. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
11. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
12. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
13. This work is a derivative of Psychology 2e by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/psychology-2e/pages/1-introduction ↵
14. Desai, S. (2014, February 25). Erikson’s psychosocial development | Individuals and society | MCAT | Khan Academy [Video].
YouTube. Licensed under CC BY-NC-SA. https://youtu.be/SIoKwUcmivk ↵
15. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme
Publishers New York, pp. 365, 372-377. ↵
16. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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17. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
18. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
19. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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1.5: Documenting and Reporting
Guidelines for Documentation
Accurate documentation and reporting are vital to proper client care. Reporting is oral communication between care providers that
follows a structured format and typically occurs at the start and end of every shift or whenever there is a significant change in the
resident. Documentation is a legal record of patient care completed in a paper chart or electronic health record (EHR). It is also
referred to as charting. Checklists and flowcharts completed in the resident’s room may also become part of the paper chart.
Documentation is used in a court of law to prove patient care was completed if a lawsuit is filed, with the rule of thumb being, “If it
wasn’t documented, it wasn’t done.” Documentation is also reviewed by other health care team members to provide holistic care.
Accurate documentation should follow these guidelines:
The client’s chart is confidential and should only be shared with those directly involved in care. If using paper, cover
information with a blank sheet. When using technology, be sure screens are visible only to you and log out after each use. Never
share security measures like passwords or PIN with anyone else.
Document as soon as any care is completed.
Include date, time, and signature per facility policy.
Use facts, not opinions. An opinion is, “The resident doesn’t like their food.” Instead, a fact should be charted, such as, “The
resident refused their meal and stated they were not hungry.”
Use measuring tools, such as a graduated cylinder or a tape measure, whenever possible to provide accurate data. If you do have
to estimate, provide a comparison such as, “Drainage noted on the bandage was the size of a quarter.”
If you chart on paper, always use a black pen. If you make a mistake, draw only one line through the entry, write the word
“mistaken entry,” and add your initials. Do not use correction fluid or completely black out the entry.
Long-term care facilities are required to complete additional documentation called a Minimum Data Set (MDS). The MDS is a
standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or
Medicaid. The MDS is completed by a registered nurse who reviews documentation by nursing assistants to complete some parts of
the MDS. Accurate documentation is vital so that facilities are appropriately reimbursed for the services provided to clients.
The MDS nurse will review the nursing assistant’s documentation pertaining to a resident’s sensory abilities, specifically their
communication skills, hearing, and vision. For this reason, documentation must be accurate and thorough regarding assistive
devices, the amount of assistance required, and skin observations. For example, devices for communication, such as whiteboards,
photo books, charts, hearing aids, or glasses, must be appropriately documented, as well as the amount of assistance required for
dressing, bathing, eating, toileting, repositioning in bed, transferring, and ambulating. Skin observations made during cares should
also be thoroughly documented so they can be included in MDS reporting.

View the MDS PDF from the Centers for Medicaid and Medicare Services.

Guidelines for Reporting

Reporting client information to other nursing assistants or to a nurse for follow-up is an important part of meeting client needs and
providing competent care. When providing an oral report, be mindful of confidentiality and where the report is given so no one
overhears private information. Appropriate places for reporting include a closed room, a nurse’s station away from resident rooms
and common areas, or in a private resident’s room with the door closed.
Throughout this textbook, specific information that should be documented and reported will be noted. Generally, a nursing assistant
should report any physical changes in a client that seem unusual or behavior that is out of the ordinary for that person. Examples
that require immediate notification to the nurse may include the following:
Strong odors from urine, oral care, or wounds
Reddened, warm, or open skin areas
Difficulty breathing or chest pain
Objective information includes information about a client that can be observed through the four senses of sight, touch, hearing, or
smell. This information is referred to as signs. Objective information can be verified by another individual and often includes

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measuring tools such as a scale, thermometer, specimen cup, or graduated cylinder. An example of objective information is the
client’s temperature was 98.6 degrees Fahrenheit.
Subjective information is information reported to you by clients or their family members. This information is referred to as
symptoms. It is documented by using the exact wording reported with quotation marks. An example of subjective information is
the resident stating, “I have a headache.”

Military Time
Military time is used to record the time care is provided and any other pertinent information for the resident. It avoids confusion
between daytime and nighttime hours because it does not require a.m. or p.m. Each hour of the day has its own number from 1 to
24 and no colons are used. Beginning at 1:00 p.m., simply add 12 to the hour. For example, 1:46 p.m. is written as 1346. For
morning hours up to 9:59 p.m., add a zero in front of the hour. For example, 9:24 a.m. is written as 0924. Midnight is documented
as either 2400 or 0000.
When reporting in military time, morning hours are pronounced beginning with “zero” or “O.” For example, 7:00 a.m. is
pronounced “zero seven hundred” or “oh seven hundred.” The time of 2:43 p.m. is pronounced “fourteen forty-three.” See Figure
[1]
1.6 below for conversion from civilian to military time.

Figure 1.6 Military Time

1. “Military Time Clock 3I3A0711.jpg” by Deanna Hoyord for Chippewa Valley Technical College is licensed under CC BY 4.0
↵

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1.6: Learning Activities

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1.7: I Glossary
Active listening: Listening while communicating verbally and nonverbally that we are interested in what the other person is saying
and also verifying our understanding with the speaker.
Activities of daily living (ADLs): Daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination,
dressing, eating, ambulating/moving).
Aggression: The act of attacking without provocation.
Aggressive communicators: Individuals who come across as advocating for their own rights when communicating despite
possibly violating the rights of others.
Agitation: Behaviors that fall along a continuum ranging from verbal threats and motor restlessness to harmful aggressive and
destructive behaviors.
Aphasia: A condition with difficulty processing what one is hearing or responding to questions due to dementia, brain injuries, or
strokes.
Assertive communication: A way of conveying information that describes the facts and the sender’s feelings without
disrespecting the receiver’s feelings.
Assertive communicators: Individuals who respect the rights of others while also standing up for their own ideas and rights when
communicating.
Autonomy: Each individual’s right to self-determination and decision-making based on their unique values, beliefs, and
preferences.
Belongingness: A human emotional need for interpersonal relationships, connectedness, and being part of a group.
Communication: A process by which information is exchanged between individuals through a common system of symbols, signs,
or behavior.
Competitive listening: Listening that occurs when we are primarily focused on sharing our own point of view instead of listening
to someone else.
Delusions: Unshakable beliefs in something that isn’t true or based on reality.
Diet and fluid orders: Orders regarding what the resident is permitted to eat and drink.
Documentation: A legal record of patient care completed in a paper chart or electronic health record (EHR).
Elimination needs: Assistance the resident requires for urinating and passing stool.
Hallucinations: A condition where a person senses things such as visions, sounds, or smells that seem real but are not.
Holistic care: Health care that addresses a patient’s physical, emotional, social, and spiritual needs.
Maslow’s Hierarchy of Needs: A theory stating that unless basic human needs within a hierarchy are met, humans cannot
experience higher levels of psychological and self-fulfillment needs.
Military time: A standard for recording time that avoids confusion between daytime and nighttime hours because each hour of the
day is represented by a number ranging from 00:00 to 24:59.
Minimum Data Set (MDS): A standardized assessment tool for all residents of long-term care facilities certified to receive
reimbursement by Medicare or Medicaid.
Nonverbal communication: Communication that includes body language and facial expressions, tone of voice, and pace of the
conversation.
Objective information: Anything that can be observed through sight, touch, hearing, or smell, referred to as “signs.” An example
of objective information is the client’s temperature was 98.6 degrees Fahrenheit.
Older adults: Adults aged 65 years old or older.
Passive communicator: Individuals who put the rights of others before their own when communicating.

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Passive listening: Listening that occurs when we are not interested in listening to the other person or we assume we correctly
understand what the person is communicating without verifying their message.
Progressive relaxation: Stress management techniques that focus on reducing muscle tension and using mental imagery to induce
calmness.
Relaxation breathing: A stress management technique focused on becoming aware of one’s breathing.
Reporting: Oral communication between care providers that follows a structured format and typically occurs at the start and end of
every shift.
Signs: Objective information obtained through the senses of sight, hearing, smell, or touch.
Stress response: The body’s response to stress that can include irritability, sweaty palms, a racing heart, difficulty concentrating,
and impaired sleep.
Subjective information: Information reported by clients or their family members referred to as “symptoms.” An example of
subjective information is the resident stating, “I have a headache.”
Symptoms: Subjective information reported by clients or their family members. Symptoms are documented by using quotes
around the exact words expressed by the client or their family member. For example, the client reported, “I have a headache.”
Therapeutic communication: A type of professional communication used with patients defined as the purposeful, interpersonal,
information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills that leads to
patient understanding and participation.
Transfer status: Assistance the patient requires to be moved from one location to another, such as from the bed to a chair.
Validation therapy: A method of therapeutic communication used to connect with someone who has moderate to late-stage
dementia and avoid agitation.

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 CHAPTER OVERVIEW

2: Demonstrate Professionalism in the Workplace

2.1: Introduction to Demonstrate Professionalism in the Workplace
2.2: Ethical and Legal Responsibilities of the Nursing Assistant
2.3: Members of the Health Care Team and Nursing Home Structure
2.4: The Nursing Process
2.5: Scope of Practice
2.6: Health Care Settings
2.7: Job-Seeking and Keeping Skills
2.8: Learning Activities
2.9: II Glossary

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1
2.1: Introduction to Demonstrate Professionalism in the Workplace
Learning Objectives
Function within and uphold the ethical and legal responsibilities of the nursing assistant
Carry out assignments
Develop job-seeking and keeping skills
Protect rights of clients
Treat all clients respectfully regardless of social, ethnic, or religious background
Apply strategies to cope with caregiver stress
Differentiate the nursing assistant role in a variety of health care settings

In this chapter you will learn about professional responsibilities associated with becoming a licensed nursing assistant. Resident
rights are at the forefront of providing care to ensure quality of life for dependent individuals. You will become familiar with the
agencies involved in regulation of long-term care, legislative acts that uphold resident rights, and the nursing assistant scope of
practice. You will gain awareness about your role within the health care team, the facility, and the nursing process, as well as the
variety of health care settings in which you may work as a nursing assistant.

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2.2: Ethical and Legal Responsibilities of the Nursing Assistant
Ethical Responsibilities of the Nursing Assistant
Nursing assistants should treat all clients equally and with compassion and respect for their inherent dignity, worth, and unique
attributes. They should promote clients’ rights and safety to assist in achieving the best possible health and functioning. Read more
about resident rights in the box later in this section.
As a student or a newly employed nursing assistant, you may find yourself in circumstances where you observe unethical behaviors
[1]
exhibited by other agency staff. Examples of unethical behavior to avoid are as follows :
Using a personal cell phone in patient care areas
Not responding to call lights promptly when you are available to do so
Ignoring the phone(s) assigned to you
Using agency computers for personal use
Avoiding clients because of their ethnicity, beliefs, demeanors, or other individual characteristics
Avoiding work by sitting in empty patient rooms or the break room during on-time work hours
Accepting gifts or gratuities from clients or their family members
Sharing clients’ personal information with others who are not providing direct care
Stealing items from clients or the health care agency

Governing Agencies
When you work as a nursing assistant, you are helping vulnerable populations. Vulnerable populations include patients who are
children, older adults, minorities, socially disadvantaged, underinsured, or those with certain medical conditions. Members of
[2]
vulnerable populations often have health conditions that are exacerbated by inadequate health care. As a result, there are many
governing agencies involved in the care of these clients to ensure their needs are met.
Federal agencies that regulate and provide guidelines for health care include the following:
Centers for Medicare and Medicaid (CMS): The CMS provides health care funding for qualifying members. Medicare is
health care funding available to anyone over the age of 65, as well as those who have a permanent disability or kidney failure.
There are four types of coverage that Medicare provides: care in hospitals and nursing homes (Part A); medical appointments,
services, and equipment (Part B); additional services provided by private companies (Part C); and prescription drug coverage
(Part D). Medicaid is health care funding available for individuals with low incomes and is provided at both the federal and
[3] [4]
state level. Both Medicare and Medicaid may cover services for resident care based on each individual’s needs. ,
[5]
Centers for Disease Control (CDC): The CDC provides guidance for facilities related to infection and disease control.
Food and Drug Administration (FDA): The FDA protects public health by ensuring the safety of medications, biological
products, medical devices, cosmetics, products that emit radiation, and the food supply. It also regulates tobacco products and
helps the public get the accurate, science-based information they need to use medical products and foods to maintain and
[6]
improve their health.
Occupational Safety and Health Administration (OSHA): OSHA ensures safe and healthy working conditions for workers
[7]
by setting and enforcing standards and by providing training, outreach, education, and assistance.
Every state has a Department of Health Services (DHS) that works with local counties, health care providers, and community
partners. The DHS provides services that aid and protect the state’s citizens, such as alcohol and drug abuse prevention programs,
mental health programs, public health services, disability determination, implementation of long-term care, and regulation of state
nursing homes, along with numerous other services.

Read more about Wisconsin’s Department of Health Services at the About the Department of Health Services (DHS) web
page.

Federal Health Care Acts

In addition to government agencies, there are federal laws that directly affect health care. The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) required the creation of national standards to protect sensitive patient health information

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from being disclosed without the patient’s consent or knowledge. The HIPAA security rule requires the following:
Ensure the confidentiality, integrity, and availability of all protected health information (PHI)
Detect and safeguard against anticipated threats to the security of the information
Protect against anticipated impermissible uses or disclosures
Certify compliance by their workforce
As a nursing assistant, this means that you must legally keep any information regarding the care of your clients confidential,
including documentation, care plans, and shift reports. Refer to the “Guidelines for Reporting” subsection in Chapter 1 for more
details about confidential reports.

Read more about HIPAA at the CDC’s Health Insurance Portability and Accountability Act of 1996 (HIPAA) web page.

The Omnibus Reconciliation Act of 1987 (OBRA) set forth new provisions for Medicare and Medicaid related to new standards
for care in the nursing home setting. One major provision was a requirement for nurse aide training. It required that new nurse aides
train for a minimum of 75 hours and pass a competency evaluation and that each state records a registry for nurse aides who have
passed the competency evaluation. It also focused on improving quality of life for residents in long-term care (LTC), focusing on
[8]
patient-centered care and meeting the preferences of each individual in making decisions regarding their care. Read more about
long-term care settings in the “Health Care Settings” section of this chapter. During patient-centered care, an individual’s specific
health needs and desired health outcomes are the driving forces behind all health care decisions. Patients are partners with the
health care team members, and health care professionals treat patients not only from a clinical perspective, but also from an
[9]
emotional, mental, spiritual, social, and financial perspective.
The Older Americans Act (OAA) was passed in 1965 in response to concern by policymakers about a lack of community social
services for older persons. The original legislation established authority for grants to states for community planning and social
services, research and development projects, and personnel training in the field of aging. It also includes states’ Long-Term Care
(LTC) Ombudsman programs that work to resolve problems related to the health, safety, welfare, and rights of individuals who live
in LTC facilities, such as nursing homes, assisted living facilities, and other residential care communities. The OAA act requires the
[10]
following of ombudsman programs :
Identify, investigate, and resolve complaints made by or on behalf of residents
Provide information to residents about long-term services and supports
Ensure that residents have regular and timely access to ombudsman services
Represent the interests of residents to governmental agencies and seek administrative, legal, and other remedies to protect
residents
Analyze, comment on, and recommend changes in laws and regulations pertaining to the health, safety, welfare, and rights of
residents

Resident Rights
As a health care regulator, the CMS ensures residents know and understand their rights and these rights are upheld. Resident rights
are the most important aspect of providing care. It is essential for health care workers to protect the dignity of residents and
enhance their quality of life. A concise list of resident rights that are protected in long-term care and other settings is described in
the following box.

 Resident Rights in Long-Term Care and Other Settings [11]

Be treated with respect

Participate in activities
Be free from discrimination, restraints, abuse, and neglect
Make complaints
Receive proper medical care
Make decisions regarding one’s care with the involvement of family and loved ones if desired
Have one’s representative notified of care and complications
Receive information about services and fees
Manage one’s money

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 Receive privacy and proper living arrangements
Spend time with visitors
Receive social services
Be protected against unfair transfers or discharges
Have the ability to leave the facility when health status allows, either temporarily or permanently
Create or participate in groups

These guidelines should be at the forefront of your mind with any resident interaction. It is important for NAs to remember that it
can be difficult for residents to accept being dependent on a caregiver for completing their ADLs. This feeling of dependency can
cause them to lose self-esteem or even lead to depression. Refer back to the exercise in the “Managing Clients’ and Family
Members’ Stress” subsection in Chapter 1 to recall how to empathize with residents. If a resident has a request, you should make
accommodations to meet their needs as appropriate. If you are unsure how to meet their request, consult with your supervising
nurse. The only reason a resident preference should not be granted would be due to safety or infection control concern. For
example, if a resident wants to have a candle in their room, the risk of fire would not allow this request, but an alternative would be
an electric candle. If a resident wanted to use a hair dryer but their roommate could possibly burn themselves due to altered safety
awareness, the facility should work to find a secure place where the resident could use the hair dryer.

For more information, read the Your Rights and Protections as a Nursing Home Resident PDF.

 Learning Activity

Resident rights quiz: Resident Rights Quizlet

Elder Abuse and Neglect

As discussed in the “Resident Rights” section, clients are to be free from abuse and neglect. Elder abuse is an intentional act, or
failure to act, that causes or creates a risk of harm to someone age 60 or older. The abuse occurs at the hands of a caregiver or a
person the older adult trusts. Neglect refers to a failure to provide care for oneself or to someone for whom you are enlisted to care.
Review Table 2.2 for types of abuse and neglect and signs or symptoms that you should report to the nurse.
[12] [13]
,
Table 2.2 Types of Abuse and Signs or Symptoms to Report

Type of Abuse Definition Signs or Symptoms

Illness, pain, injury, functional impairment, Bruising, fractures, burns, or any other
distress, or death as a result of the intentional unexplainable injury. The abused person may
Physical use of physical force. This includes acts such isolate themselves, withdraw from
as hitting, kicking, pushing, slapping, and conversation, or change behavior when the
burning. abuser is present.

Forced or unwanted sexual interaction of any Injury to genital areas, rashes, infections,
kind. This may include unwanted sexual bleeding or discharge from genitals, torn
Sexual
contact, penetration, or noncontact acts such as clothing, and behavioral changes listed under
sexual harassment. “Physical” abuse “Signs or Symptoms.”

Verbal or nonverbal behaviors that inflict

anguish, mental pain, fear, or distress on an
older adult. Examples include humiliation or Depression, anxiety, loss of self-confidence or
Emotional or Psychological
disrespect, verbal and nonverbal threats, motivation, or feelings of failure.
control of one’s actions, harassment, or
isolation from other loved ones.

Illegal, unauthorized, or improper use of an Missing items; going without food,

older adult’s money, benefits, belongings, medications, or other necessities; or excessive
Financial
property, or assets for the benefit of someone use of cash if they cannot account for the
other than the older adult. spending.

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 Failure to meet an older adult’s basic needs, Weight loss, skin breakdown, infection,
Neglect including food, water, shelter, clothing, confusion, hallucinations, dehydration, soiled
hygiene, and essential medical care. linens and clothing, odors, or poor oral care.

Lack of self-care that threatens personal health

See “Signs or Symptoms” listed under
Self-Neglect and safety, including a failure to seek help for
“Neglect.”
care.

Nursing assistants and other health care professionals are referred to as mandated reporters because they are required by state law
to report suspected neglect or abuse of the elderly, vulnerable adults, and children. As a caregiver, you are required to report any
signs or symptoms that are suspicious for abuse or neglect to the nurse. At the time of the finding, you must stay with the resident
until you can ensure that no further abuse or neglect occurs, even if you are in a facility. If a resident reports any abuse, you are
obligated to inform the nurse, charge nurse, or an administrator, regardless of the cognitive function of the person reporting so that
an investigation can be performed.

The Survey Process

Each state’s Department of Health Services (DHS) conducts surveys of long-term care (LTC) facilities under the guidelines
provided by the CMS. Standard surveys typically occur at least one time per year. During a survey, DHS employees observe care
provided to residents, watch preparation and serving of food, review resident care plans and facility documentation, interview
residents and families, and look at every aspect of the facility. The surveyors are ensuring that all aspects of residents’ physical,
emotional, social, and spiritual needs are met. If you are a nurse aide being observed or interviewed, it is important to only provide
facts. If you do not know the answer to a question, respond that you do not know the answer and explain that you will find an
answer as soon as possible. You can offer things like, “I need to check my care plan for that information,” or “I would ask the nurse
[14]
for clarification,” as appropriate to the question.
If a problem or discrepancy is discovered during a survey, the facility receives a citation from the surveyors. At the end of the
survey process, DHS will conduct an exit interview with the Administrator, Director of Nursing (DON), and other facility
leadership. When residents are found to be at a high risk for adverse events, the surveyors will ask the facility to create a plan to
correct the issues. DHS will make a return visit in a few weeks to follow up on the implementation.
DHS may also conduct a survey if they have received several complaints from residents or family members or if certain events
occur such as elopement of a resident or an accident with a major injury. Elopement is defined as an event when a resident who is
incapable of protecting themselves from harm is able to successfully leave the facility unsupervised and unnoticed and possibly
[15]
enter into harm’s way.
The results of a survey must be made available to the public. They must be posted at the entrance to the facility, along with
information on how to contact the ombudsmen. They are also available electronically at medicare.gov.

Read ratings of nursing homes and survey results: Medicare.gov Provider Comparison Tool.

1. Miller-Hoover, S. (2018). I said what? Professionalism for the CNA. RN.com. https://www.rn.com/featured-
stories/professionalism-
cna/#:~:text=Professional%20CNAs%20are%20responsible%2C%20trustworthy,and%20being%20a%20team%20player ↵
2. Waisel, D. B. (2013). Vulnerable populations. Current Opinion in Anaesthesiology, 26(2), 186-192.
https://doi.org/10.1097/aco.0b013e32835e8c17 ↵
3. Medicare.gov. U.S. Centers for Medicare and Medicaid Services. https://www.medicare.gov/ ↵
4. Medicaid.gov. U.S. Centers for Medicare and Medicaid Services. https://www.medicaid.gov/ ↵
5. Centers for Disease Control and Prevention. (2021, September 24). About CDC 24-7. https://www.cdc.gov/about/default.htm ↵
6. U.S. Food & Drug Administration. (2018, March 28). What we do. https://www.fda.gov/about-fda/what-we-do ↵
7. Occupational Safety & Health Administration. (n.d.). About OSHA. United States Department of Labor.
https://www.osha.gov/aboutosha ↵
8. Kelly, M. (1989). The omnibus budget reconciliation act of 1987. A policy analysis. The Nursing Clinics of North America,
24(3), 791-794. https://pubmed.ncbi.nlm.nih.gov/2671955/ ↵

2.2.4 https://med.libretexts.org/@go/page/70296
 9. NEJM Catalyst. (2017, January 1). What is patient-centered care? Massachusetts Medical Society.
https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559 ↵
10. Administration for Community Living. (2021, November 24). Long-term care ombudsman program.
https://acl.gov/programs/Protecting-Rights-and-Preventing-Abuse/Long-term-Care-Ombudsman-Program ↵
11. Centers for Medicare & Medicaid Services. (n.d.). Residents' rights & quality of care. https://www.cms.gov/nursing-
homes/patients-caregivers/residents-rights-quality-care ↵
12. Centers for Disease Control and Prevention. (2021, June 2). Preventing elder abuse.
https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html ↵
13. Washington State Department of Social and Health Services. (n.d.). Self-neglect. https://www.dshs.wa.gov/node/2444/#signs ↵
14. Institute of Medicine (US), Committee on Nursing Home Regulation. (1986). Improving the quality of care in nursing homes.
National Academies Press (US); 1986. 4, Monitoring nursing home performance.
https://www.ncbi.nlm.nih.gov/books/NBK217555/ ↵
15. Institute of Medicine (US), Committee on Nursing Home Regulation. (1986). Improving the quality of care in nursing homes.
National Academies Press (US); 1986. 4, Monitoring nursing home performance.
https://www.ncbi.nlm.nih.gov/books/NBK217555/ ↵

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and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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2.3: Members of the Health Care Team and Nursing Home Structure
[1]
As illustrated in Figure 2.1 below, the resident and their family members are at the center of holistic care. We know from Chapter
1 that holistic care includes physical, emotional, social, and spiritual well-being. A holistic approach focuses on a person’s wellness
and not just their physical illness or condition. Each member of the health care team provides holistic care to achieve the best
possible health outcomes for clients and improve their quality of life. Responsibilities of the health care team members are as
follows:
Physicians and health care providers diagnose conditions and prescribe medications and treatments.
Nursing service members include registered nurses (RNs), licensed practical nurses/vocational nurses (LPNs/VNs), certified
medical technicians (CMTs), and nursing assistants (RNAs, LNAs, CNAs). The nursing team implements nursing care plans
based on the nursing process and provider orders. The nursing supervisor/charge nurse/unit manager supports the nursing staff
and may assist in providing resident care or treatments. Staff/Floor nurses provide nursing care to residents. Nursing assistants
perform assigned or delegated nursing tasks such as assisting with ADLs and reporting any changes in a resident’s condition.
Social Services, such as social workers and case managers, assist with emotional and personal problems, benefit coordination,
and any discharge or transfer needs to other facilities.
Therapists, such as physical therapy (PT), occupational therapy (OT), and speech therapy (ST), assist residents in recovering
from an illness to return to and maintain function. Therapy roles are further outlined in Chapter 9.

Figure 2.1 Members of the Health Care Team

Each department and member of the health care team is essential for quality resident care. Although there are a variety of
certifications, skills, and abilities present within the health care team, each component is a valued resource. Your part in the team as
a nursing assistant is to understand team member roles and responsibilities, coordinate with the appropriate team members when
needed, and respect and support each team member’s efforts. You should expect the same treatment from other health care team
members regardless of their educational background, title, or job duties.
While the health care team provides care for residents in the nursing home, other departments and individuals oversee business and
non-health care operations for the facility. A nursing assistant should have an understanding of the non-medical aspects necessary
to meet resident needs.
Non-health care responsibilities of team members in a nursing home include the following:
Administrator: Oversees federal and state regulation compliance and manages non-medical aspects of the facility, such as
finance.
Medical Director: Consults on medical aspects of care, such as infection control and quality of care.
Director of Nursing (DON): Manages all aspects of nursing staffing, policies, and procedures.
Assistant DON: Assists with managing nursing staff and implementing policies and procedures.
Staff Development Coordinator (SDC): Trains nursing employees and provides continuing education.
Minimum Data Set (MDS) Coordinator: Assesses resident needs and reports to CMS for reimbursement.
Business Office: Oversees billing and other financial aspects.
Housekeeping and Maintenance: Maintains the facility and equipment and keeps the environment clean and safe.
Activities Director: Oversees any activities staff members provide and plans events for resident enjoyment related to hobbies
or interests.
Dietary Director: Oversees dietary staff to deliver nutritional and fluid needs of residents.
[2]

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 [2]
See Figure 2.2 for an illustration of the general structure of a LTC facility.

Figure 2.2 General Structure of a LTC Facility

1. This image is a derivative of “img4.jpg” by Branden Morton. This image is included on the basis of Fair Use. ↵
2. “General Structure of a LTC Facility” by Myra Sandquist-Reuter for Chippewa Valley Technical College is licensed under CC
BY 4.0 ↵

This page titled 2.3: Members of the Health Care Team and Nursing Home Structure is shared under a CC BY 4.0 license and was authored,
remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a
detailed edit history is available upon request.

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2.4: The Nursing Process
The nursing process is a critical thinking model based on a systematic approach to patient-centered care that nurses use to perform
clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of
Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements
of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform
[1]
competently. The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process, with each letter
referring to the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation,
[2]
and Evaluation. See an illustration of the cyclical nursing process in Figure 2.3.

Figure 2.3 The Nursing Process

Assessment
The Assessment component of the nursing process is defined as, “The registered nurse collects pertinent data and information
[3]
relative to the health care consumer’s health or the situation.” A nursing assessment includes physiological data, as well as
psychological, sociocultural, spiritual, economic, and lifestyle data. Nursing assistants should observe and report things to the nurse
[4]
that they notice when providing care, such as reddened or open skin, confusion, increased swelling, or reports of pain.

Diagnosis
The Diagnosis phase of the nursing process is defined as, “The registered nurse analyzes the assessment data to determine actual or
[5]
potential diagnoses, problems, and issues.” A nursing diagnosis is the nurse’s clinical judgment about the client’s response to
actual or potential health conditions or needs. Nursing diagnoses are the basis for the nursing care plans and are different than
[6]
medical diagnoses.

Outcomes Identification
The Outcomes Identification phase of the nursing process is defined as, “The registered nurse identifies expected outcomes for a
[7]
plan individualized to the health care consumer or the situation.” The nurse sets measurable and achievable short- and long-term
[8]
goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses. Nurses may
communicate expected outcomes to nursing assistants, such as, “The client will walk at least 100 feet today.”

Planning
The Planning phase of the nursing process is defined as, “The registered nurse develops a collaborative plan encompassing
strategies to achieve expected outcomes.” Assessment data, nursing diagnoses, and goals are used to select evidence-based nursing
interventions customized to each patient’s needs and concerns. Goals and nursing interventions are documented in the patient’s
[9]
nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care.

Nursing Care Plans

Nursing care plans are part of the Planning step of the nursing process. A nursing care plan is a type of documentation created by
registered nurses (RNs) that describes the individualized planning and delivery of nursing care for each specific patient using the
nursing process. Nursing care plans guide the care provided to each patient across shifts so care is consistent among health care
personnel. Some nursing interventions can be assigned or delegated to licensed practical nurses (LPNs) or nursing assistants with
[10]

2.4.1 https://med.libretexts.org/@go/page/70298
 [10]
the RN’s supervision. Although nursing assistants do not create or edit care plans, they review this document to know what care
should be provided to each client within their scope of practice.

Implementation
[11]
The Implementation phase of the nursing process is defined as, “The nurse implements the identified plan.” Nursing
interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple
nurses and health professionals caring for the patient. Interventions are also documented in the patient’s medical record as they are
[12]
completed. The nursing assistant’s largest responsibility during the nursing process is safely implementing their delegated
interventions in the nursing care plan.

Evaluation
The Evaluation phase of the nursing process is defined as, “The registered nurse evaluates progress toward attainment of goals and
[13]
outcomes.” During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the
effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care
must be continuously evaluated and modified as needed. To assist the nurse in evaluation, nursing assistants must report any
changes in patient condition or new observations related to new interventions. Because nursing assistants spend the most time with
the residents, it is important to communicate with the nurse if asked to implement an intervention that is known to be ineffective
with a resident so a different, more effective alternative can be identified.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for all members of the health care team. The benefits of using the nursing process
[14]
include the following :
Promotes quality patient care
Decreases omissions and duplications
Provides a guide for all staff involved to provide consistent and responsive care
Encourages collaborative management of a patient’s health care problems
Improves patient safety
Improves patient satisfaction
Identifies a patient’s goals and strategies to attain them
Increases the likelihood of achieving positive patient outcomes
Saves time, energy, and frustration by creating a care plan or path to follow

1. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
2. “The Nursing Process” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
3. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
7. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
10. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
11. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
12. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
13. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
14. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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2.5: Scope of Practice
Scope of practice is defined as services that a trained health professional is deemed competent to perform and permitted to
[1]
undertake according to the terms of their state professional license. Different states have some variability in what nursing
assistants can legally perform based on their licensure. It is important to check state DHS regulations to know exactly what skills
and care you are able to legally provide as a nurse aide.
The CMS defines acceptable scope of practice for nursing aides at the federal level. Federal regulation 42 CFR § 483 lists nine
[2]
tasks that are allowable by each state. These tasks are as follows :
Personal care skills
Safety/emergency procedures
Basic nursing skills
Infection control
Communication and interpersonal skills
Care of cognitively impaired residents
Basic restorative care
Mental health and social service needs
Residents’ rights
As you learned in the “Nursing Process” section of this chapter, many tasks in the Implementation phase can be assigned or
delegated by the registered nurse (RN) to the nurse aide. To keep you and your residents safe, use the 4 S’s to verify that you are
performing within your scope of practice when accepting delegated or assigned tasks: Scope, Supervision, Safety, and Supplies. It
is important that you ask yourself these questions before performing any cares for a resident:
Scope: Is this task within my scope of practice as defined by my state licensure? If it is a skill or task that you did not perform
for evaluation by your instructor during your nursing assistant course, it may not be legal for you to carry out under your
licensure. However, some states allow facilities to provide additional training on skills to improve resident care.
Supervision: Do I have supervision available? Each task delegated to you must be clear and supervised. If you are unsure of
exactly what you need to perform, you should have an RN supervisor to whom you can direct questions. Supervision can be in
person or via telephone.
Safety: Am I safe to perform the task? Patient safety is vital. Even though you may have competently demonstrated a skill
when you took your certification course, there may be tasks that you do not perform consistently depending on your care
setting. For example, if you haven’t recently used a mechanical lift, you may need additional training before you can safely
perform this transfer technique with a resident.
Supplies: Do I have the supplies I need? If you do not have the proper equipment needed for the task, it is unsafe to perform it.
Supplies may include personal protective equipment (PPE) for infection control, transfer equipment and mobility aids, or
personal items needed for resident grooming and hygiene.

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. McMullen, T. L., Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R. (2015). Certified nurse aide
scope of practice: State-by-state differences in allowable delegated activities. Journal of the American Medical Directors
Association, 16(1), 20-24. https://doi.org/10.1016/j.jamda.2014.07.003 ↵

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2.6: Health Care Settings
Caregivers who provide assistance in activities of daily living (ADLs) work in a variety of settings. When an individual is no
longer able to independently care for oneself, the level of care needed is what determines where they reside. For example, an
individual who is able to perform most of their ADLs but needs assistance with meals and laundry may live in an assisted living
facility, but someone who needs more assistance with daily ADLs may live in a nursing home. As you become more familiar with
health care delivery, you will discover what type of setting will be the best fit for you. Some settings require licensure for nurse
aides while others will provide training at the agency level. Table 2.6 outlines the different types of settings where health care can
be delivered. Terms such as patients, clients, residents, and members are used interchangeably for people for whom nursing
assistants provide care. In general, people receiving care in hospitals are referred to as “patients,” people who live long-term care
facilities are referred to as “residents,” and people receiving outpatient care are often referred to as a “clients” or “members.”
Table 2.6 Health Care Settings

Type of Care What are Users Who Provides

Care Setting Typical Patient Room Environment
Provided Called? ADLs?

24-hour care is
provided with access
to physicians and
other providers, RNs,
speech therapists,
physical therapists, Designed for short
occupational stays with sterile and
therapists, respiratory clean environments.
therapists, social Rooms are typically
workers, registered Anyone with made for one patient
Patient Care
dietitians, and emergent or urgent and contain multiple
Assistants (PCAs) or
chaplains for spiritual health care concerns pieces of medical
Hospital Patients Certified Nursing
care. Hospitals is appropriate to be equipment to avoid
Assistants (CNAs);
provide acute and served in the hospital HIPAA and infection
licensure is required.
specialty care for setting. control concerns.
patients, as well as Many disposable or
emergency and urgent one-time use items
care. Some hospitals are used to avoid
provide home health cross-contamination.
and hospice services.
Larger hospitals
provide various types
of labs and diagnostic
tests on site.

A long-term care
24-hour skilled care facility, commonly
is provided for people referred to as nursing
who are no longer home or rehabilitation
Typically, older adults
eligible for hospital center, is where a
with chronic
care but are unable to person lives. The
conditions such as Certified Nursing
care for themselves at facility typically has
physical disabilities, Assistants (CNAs);
Long-term Care home. An RN is both private and
heart disease, prior licensure is required at
(LTC) or Nursing always on site. shared rooms, and Residents
strokes, diabetes, facilities that are
Home (NH) Residents may be residents are
history of major funded by Medicare
admitted due to encouraged to have
fractures, or are and Medicaid.
physical limitations in their own belongings.
otherwise unsafe at
mobility, Rooms are accessible
home.
management of for various mobility
chronic conditions or needs but are more
medication, or both. homelike than a
hospital setting.

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 Typically, residents
Care is provided that
are 65 years or older
can be scheduled,
and are more
such as medication
independent than in
assistance, grooming,
other LTC facilities.
showering, meal
They are medically Each room is like an Daily Living
preparation, cleaning,
stable but need some apartment with a Assistants (DLAs) or
Assisted Living and laundry. On- Residents
oversight for safety small kitchen and CNAs; licensure is not
demand care, such as
and home entry doors that lock. required.
assistance with
maintenance. As their
toileting or getting
assistance needs
from one place to
change, they can be
another, is not
moved to a different
included.
area if necessary.

Residents have a
Typically, adults with
bedroom and access
developmental
Provides daily care to the whole house. Daily Living
disabilities or
Group Home/Adult and maintenance with Each state provides a Assistants (DLAs) or
moderate dementia, or Residents or clients
Family Home mostly an oversight maximum capacity CNAs; licensure is not
those recovering from
on safety. per house, but group required.
substance use
homes typically have
disorders.
4-6 residents.

Can be short-term
assistance for things
like wound care or IV
Any assistance Daily Living
therapy or long-term
(nursing or ADLs) Care is provided in Patient, client, or Assistants (DLAs) or
Home Health assistance with
provided in the client’s home. member CNAs; licensure is not
medication
someone’s home. required.
management,
cleaning, shopping,
etc.

Care is available 24
Those who are Daily Living
Assistance provided hours, 7 days a week
terminally ill and/or Patient, client, or Assistants (DLAs) or
Hospice for palliative or end- in a resident’s home,
have a life expectancy member CNAs; licensure is not
of-life care. LTC facility, or
of six months or less. required.
hospital unit.

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2.7: Job-Seeking and Keeping Skills
After completing your coursework, the next step to becoming an employed nursing assistant is to find employment opportunities.
You can use local resources, such as newspapers or workforce entities, websites, or social media pages of local health care
facilities, or conduct your own search online. After you have completed your clinical experiences, keep in mind the type of facility
you prefer to work in and seek out those opportunities for greater job satisfaction. As discussed in “The Survey Process” subsection
of this chapter, you can review the survey data of nursing homes to determine their current quality ratings. It is also important to
consider staffing ratios when applying for a job. Staffing ratios refer to the number of patients assigned each shift to nurses and
nursing aides. Working for a facility with good staffing ratios can positively impact your stress level and work-life balance, making
this an important characteristic to consider.
You should create a resume to submit with your job application. A resume is a factual presentation of yourself that lists your
various skills and accomplishments. The goal of your resume is to make an employer want to interview you. Your resume should
include your contact information, education, licenses or certifications, and your work experience. You can include skills attained
during your nursing assistant training that will pertain directly to the position for which you are applying. You may want to add any
honors, awards, or volunteer experiences that would be helpful in highlighting your skills for the position you are seeking. You
should also have 2-3 professional references available. References are people who have supervised you in previous jobs or
instructors who have observed your skills. Be sure to ask individuals if you can use them as a reference before giving their contact
[1]
information to your prospective employer.
When you receive a request from a potential employer for an interview, there are many things you can do to prepare yourself. Look
at the job description and be able to specifically state how you can meet the requirements of the job. It is helpful to have someone
ask you practice questions. During an interview you are also considering if the facility is a good fit for you. You may want to
consider asking for a tour of the facility to observe the environment. Think of questions you want to know about the job such as the
following:
How long is the orientation period?
What hours will I be expected to work?
How will I be evaluated?
On the day of the interview, be sure to arrive 10-15 minutes early and have your cell phone silenced. When you meet the person
with whom you will interview, make good eye contact and shake hands if appropriate. Speak confidently and truthfully about your
abilities. Additionally, you should follow these grooming guidelines:
Shower, brush your teeth, groom your hair, and trim your nails.
Wear clean, professional attire without wrinkles, words, or logos.
If you wear a skirt or dress, make sure it is knee-length or below.
Do not wear shorts or jeans.
Wear closed-toed shoes that are in good condition.
Keep makeup and jewelry to a minimum.
Use deodorant but no cologne or perfume.
These are all grooming expectations of health care professionals, and it is important to display these qualities the first time you
meet your prospective employer.
After you are hired, refer to the areas discussed in “Communication Within the Health Care Team” to meet the needs of your
residents and build professional relationships with other staff. Based on the facility’s policies, you will have periodic evaluations
with your supervisor to discuss your job performance. It is good to reflect on your own performance before the evaluation and be
open to any opportunities discussed to improve your care. Be sure to keep your certification and any other training requirements
current so you do not have a lapse in your availability to your residents and peers.
Being a caregiver and helping others can be extremely rewarding, but at times it can also be challenging. Be sure to take care of
yourself by getting proper rest, exercise, and nutritional intake. If you don’t feel well, you can’t take care of others. Refer to
information on “Dealing With Stress” in Chapter 1 as to how you can keep yourself mentally healthy to meet the demands of your
job.

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 1. Chippewa Valley Technical College. (n.d.). Career planning. https://www.cvtc.edu/experience-cvtc/student-services/career-
planning ↵

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2.8: Learning Activities

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2.9: II Glossary
Citation: A problem or discrepancy found during a survey of a facility by the Department of Health Services.
Elder abuse: An intentional act, or failure to act, that causes or creates a risk of harm to someone 60 or older. The abuse occurs at
the hands of a caregiver or a person the older adult trusts.
Elopement: An event when a resident who is incapable of protecting themselves from harm is able to successfully leave the
facility unsupervised and unnoticed and possibly enter into harm’s way.
Health Insurance Portability and Accountability Act of 1996 (HIPAA): Legislation that required the creation of national
standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
Mandated reporter: Nursing assistants and other health care professionals are referred to as mandated reporters because they are
required by state law to report suspected neglect or abuse of the elderly, vulnerable adults, and children. As a caregiver, you are
required to report any signs or symptoms that are suspicious for abuse or neglect to the nurse.
Neglect: Failure to provide care to oneself or to someone for whom you are enlisted to care.
Nursing care plan: A type of documentation created by registered nurses (RNs) that describes the individualized planning and
delivery of nursing care for each specific patient using the nursing process.
Nursing process: A critical thinking model based on a systematic approach to patient-centered care that nurses use to perform
clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of
Professional Nursing Practice established by the American Nurses Association (ANA). The mnemonic ADOPIE is an easy way to
remember the ANA Standards and the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification,
[1]
Planning, Implementation, and Evaluation.
Patient-centered care: A model of health care where an individual’s specific health needs and desired health outcomes are the
driving force behind all health care decisions. Patients are partners with the health care team members, and health care
professionals treat patients not only from a clinical perspective, but also from an emotional, mental, spiritual, social, and financial
perspective.
Resume: A factual presentation of yourself that lists your various skills and accomplishments.
Scope of practice: Services that a trained health professional is deemed competent to perform and permitted to undertake
[2]
according to the terms of their professional license.
Staffing ratios: The number of patients assigned each shift to nurses and nursing aides.
Survey: An evaluative visit by state Department of Health Services (DHS) employees to observe care provided to residents, watch
preparation and serving of food, review resident care plans and facility documentation, interview residents and families, and look at
every aspect of the facility. The surveyors are ensuring that each aspect of residents’ physical, emotional, social, and spiritual needs
are met.
Vulnerable populations: Patients who are children, older adults, minorities, socially disadvantaged, underinsured, or those with
certain medical conditions. Members of vulnerable populations often have health conditions that are exacerbated by unnecessarily
[3]
inadequate health care.

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
3. Waisel, D. B. (2013). Vulnerable populations. Current Opinion in Anesthesiology, 26(2), 186-192.
https://doi.org/10.1097/aco.0b013e32835e8c17 ↵

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 CHAPTER OVERVIEW

3: Maintain a Safe Health Care Environment

3.1: Introduction to Maintain a Safe Health Care Environment
3.2: Emergency Situations
3.3: Resident Environment
3.4: Body Mechanics and Safe Equipment Use
3.5: Skills Checklist- Making an Unoccupied Bed Checklist
3.6: Skills Checklist- Making an Occupied Bed
3.7: Learning Activities
3.8: III Glossary

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1
3.1: Introduction to Maintain a Safe Health Care Environment
Learning Objectives
Maintain a safe, clean, comfortable, therapeutic environment
Respond appropriately in emergency situations
Perform airway clearance maneuver
Apply principles of body mechanics
Demonstrate safe use and maintenance of equipment and supplies
Make an occupied and unoccupied bed

Nursing assistants must provide safe, clean, comfortable environments and safely use equipment and supplies. This chapter will
review common emergency situations and provide guidelines on how a nursing aide should respond. A typical nursing home
environment will be described, and strategies for helping residents transition from living independently to residing in a facility will
also be discussed. Proper equipment and body mechanics for lifting residents will also be described to help keep you and those you
care for safe.

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and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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3.2: Emergency Situations
Nursing assistants must be prepared to respond to emergency situations when providing patient care. Common situations requiring
immediate emergency response include heart attacks (myocardial infarctions), strokes (cerebrovascular accidents), seizures, falls,
fires, and choking.

Heart Attack or Myocardial Infarction (MI)

Myocardial infarction (MI) is the medical term for what is commonly referred to as a “heart attack.” It is caused by a lack of
blood flow and oxygen to a region of the heart, resulting in the death of cardiac muscle cells. An MI is typically caused by a
blocked coronary artery that occurs when the buildup of plaque creates a clot or when a piece of the plaque breaks off and travels to
a smaller vessel, creating a blockage.
When the cardiac muscle cells are starved of oxygen and begin to die during an MI, there is typically a sudden onset of severe pain
called angina beneath the sternum. This pain often radiates down the left arm or into the jaw. However, some patients (especially
female patients) may not experience severe pain but instead experience symptoms that feel like indigestion. Patients may also have
associated symptoms like difficulty catching their breath referred to as shortness of breath (SOB), sweating, anxiety, irregular
heartbeats, nausea, vomiting, or fainting. Symptoms should be immediately reported to the nurse for emergency assessment and
[1] [2]
treatment to preserve as much of the heart as possible. See Figure 3.1 for an illustration of a male experiencing a myocardial
infarction.

Figure 3.1 Myocardial Infarction

[3]
View the following supplementary TED-Ed video with additional information on heart attacks:
What Happens During a Heart Attack? – Krishna Sudhir.

Stroke or Cerebrovascular Attack (CVA)

A cerebrovascular attack (CVA), often referred to as a “stroke” or “brain attack,” is caused by a lack of blood flow and oxygen to
the brain, resulting in the death of brain cells within a few minutes. Similar to the cause of a heart attack, the lack of blood flow is
often caused by a blockage in an artery, but in the case of a stroke, the artery is located in the brain. Strokes can also be caused by a
blood vessel in the brain rupturing and bleeding, called a hemorrhagic stroke. Risk factors for strokes include smoking, high blood
pressure, and cardiac arrhythmias (i.e., irregularities in heart rate and/or rhythm).
Lack of blood flow to the brain for more than a few minutes causes irreversible brain damage. The longer a person goes without
treatment for a stroke, the more damage that occurs to their brain cells. Damaged brain cells can result in paralysis, cognitive
impairment, difficulty speaking and understanding words, and mood swings. For this reason, it is important to recognize early signs
of a stroke and obtain rapid emergency treatment.
The treatment for a stroke depends on the cause. Eighty percent of strokes occur due to a blockage of an artery in the brain. Strokes
[4]
caused by a blockage are treated with thrombolytic medication (such as tPA) to dissolve the clot. See Figure 3.2 for an image of
a stroke caused by a blockage. Hemorrhagic strokes occur due to a ruptured vessel in the brain. These types of strokes often require
surgery to stop the bleeding. Stroke treatments work best if the symptoms of a stroke are recognized early and emergency treatment
[5]
occurs within three hours of the onset of symptoms.

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 Figure 3.2 Stroke
Strokes typically affect one side of the brain based on where the blood flow was disrupted. Because of the brain’s anatomy, the
symptoms of a stroke occur on the opposite side of the body as the affected side of the brain. For example, if a stroke occurs in the
left side of the brain, the right side of the body will be affected, resulting in signs and symptoms occurring only on the right side of
the body. This unilaterality (i.e., one-sidedness) of symptoms is important to recognize and report to the nurse.
The FAST acronym is used to remember early signs of a stroke:
F: Facial drooping
A: Arm weakness (unilateral)
S: Slurred speech
T: Time, meaning the quicker the response, the better the outcome
Given the central role and vital importance the brain is to life, it is critical that its blood supply remains uninterrupted. If blood flow
is interrupted, even for just a few seconds, a transient ischemic attack (TIA), also called ministroke, may occur. A TIA is a
temporary period of symptoms similar to those of a stroke, but they usually last only a few minutes, and they don’t cause
permanent brain damage. However, TIAs can be a warning sign for a future stroke and should be reported to the nurse.

View a YouTube video[6] from the Centers for Disease Control and Prevention (CDC): Recognizing the Signs and Symptoms
of Stroke

Seizure
A seizure is a transient occurrence of signs and/or symptoms due to abnormal activity in neurons in the brain. During a seizure,
large numbers of brain cells are abnormally activated at the same time, like an electrical storm in the brain. This abnormal neuronal
activity often affects a person’s consciousness and causes abnormal muscle movements.
Seizures are generally described in two major groups: generalized seizures and focal seizures. The difference between the types of
[7]
seizures is in how and where they begin in the brain.
Many symptoms can occur during a seizure. They are classified as motor or nonmotor symptoms. Motor symptoms include the
[8]
following :
Sustained rhythmic jerking movements (clonic)
Muscles becoming limp or weak (atonic)
Body, arms, or legs becoming stiff or tense (tonic)
Brief twitching (myoclonus)
[9]
Nonmotor symptoms are as follows :
Staring spells (absence seizures)
Changes in sensation, emotions, thinking, or autonomic functions (nonmotor symptoms)
Lack of movement (behavioral arrest)
[10]
When reporting a seizure to the nurse, include the following three descriptions :
The time the seizure started
The person’s level of awareness during the seizure
The movements that occurred during the seizure

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If a resident has seizure disorder, it is typically noted in the nursing care plan. If you witness the beginning of a seizure, prepare to
take quick action to reduce the chance of injury. For example, if the person is standing, the seizure can cause them to fall. You may
not be able to stop the fall but try to guide them to the floor if possible. After they are on the floor, protect their head from directly
hitting the floor by placing a pillow or your leg underneath their head. During the seizure, the person may bite their tongue or gag.
However, do not place anything in their mouth because this will increase the risk of choking.
Immediately notify the nurse if you observe the start of a seizure and note the time it started. When the seizure has ended, carefully
assist the person into bed. Due to the trauma experienced during the seizure, it is typical for the person to sleep for several hours.
Some individuals with seizure disorders may also receive antianxiety medication to prevent another seizure from occurring.

[11]
View the Epilepsy Foundation’s YouTube video of a person experiencing a seizure: Wendy says #ShareMySeizure.
[12]
View the Epilepsy Foundation’s YouTube video to learn more about seizure first aid : Responding to Seizures: Care and
Comfort First Aid.

Falls and Fall Prevention

Falls are common in adults aged 65 years and older. In the United States, about a third of older adults who live at home and about
half of people living in nursing homes fall at least once a year. There are many factors that increase the risk of falling in older
adults. These risk factors include mobility problems, balance disorders, chronic illnesses, and impaired vision. Many falls cause
injury, ranging from mild bruising to broken bones, head injuries, and even death. In fact, falls are a leading cause of death in older
adults.
If you enter a room and discover a resident has fallen, do not move them unless they are in immediate danger of further injury.
Notify the nurse as soon as you observe the situation so the resident can be assessed and treated. Typically, a mechanical lift will be
used to raise the resident from the floor to prevent injury to themselves and staff.
As a nursing assistant, there are several actions you can take to prevent falls. Keep the environment clean and free of clutter that
can cause imbalance while a resident is ambulating (i.e., walking). If a spill is noted on the floor, it should be cleaned up
immediately. Whenever residents are standing or walking, be sure they are wearing nonskid footwear (i.e., shoes or socks with
rubberized soles). Use ordered assistive devices, such as gait belts and walkers, when moving a resident. If a resident wears glasses
or hearing aids, make sure they are functioning, clean, and properly fitted for the resident so the resident can safely assess their
[13]
surroundings when moving. Additional information on fall risk and preventing falls can be found in Chapter 9.

Fire
In Chapter 2 you learned about agencies that govern health care, such as the Occupational Safety and Health Administration
(OSHA). OSHA provides fire regulations and guidelines for every place of employment. This knowledge is essential for keeping
residents safe in health care settings due to their limited mobility. Compliance to these regulations when responding to fires is
commonly reviewed during the survey process.
[14]
The response to a fire can be remembered by the RACE and PASS acronyms. See Figure 3.3 for using the PASS method with a
fire extinguisher.
R: Rescue anyone in immediate danger from the fire if it doesn’t endanger your life.
A: Activate the alarm by pulling the nearest fire alarm or calling 911.
C: Contain the fire by closing all doors and windows.
E: Extinguish the fire if it is small enough using a fire extinguisher and the PASS method. If the fire cannot be extinguished,
then evacuate patients and oneself from the area. The PASS method includes the following actions:
P: Pull the pin on the fire extinguisher.
A: Aim the extinguisher nozzle at the base of the fire.
S: Squeeze or press the handle.
S: Sweep from side to side at the base of the flame until the fire appears to be out.

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 Figure 3.3 RACE for Fire Safety

[15]
View the UC San Diego Health’s YouTube video on using RACE + PASS: RACE + PASS Training.

Choking and Airway Clearance

Choking is a common cause of unintentional injury and death. Over half of the people who die from choking are over the age of 70.
[16]
Food is often responsible for choking incidents in the elderly, especially those who have difficulty swallowing or have dentures.
Many people who have dementia or who have had a previous stroke have difficulty swallowing. If you see any signs of choking,
immediately notify the nurse and take action to clear the person’s airway.
If you are in a setting without a nurse present, it is important for you to know what to do and how to rescue someone who is
choking. If a person is continuing to cough forcefully, encourage continued coughing to clear the object. However, a person who
can’t cough, speak, or breathe needs immediate help. Ask the person if they are choking and let them know you will use abdominal
thrusts, known as the Heimlich maneuver, to help them clear their airway and breathe. (Keep in mind the Heimlich maneuver is
[17]
not recommended for children younger than 1.) See Figure 3.4 for an image of the Heimlich maneuver.

Figure 3.4 Heimlich Maneuver

[18]
To perform the Heimlich maneuver, perform the following steps :
Stand behind the victim with one leg forward between the victim’s legs. If the person is sitting in a wheelchair or not able to
stand, lean them forward in the chair and stand behind them.
For a child, move down to their level and keep your head to one side.
Reach around the abdomen and locate the navel.
Place the thumb side of your fist against the abdomen just above the navel.
Grasp your fist with your other hand and thrust inward and upward into the victim’s abdomen with quick jerks.
For a responsive pregnant victim, any victim you cannot get your arms around, or for anyone in whom abdominal thrusts are
not effective, give chest thrusts while standing behind them. Avoid squeezing the ribs with your arms.
Continue thrusts until the victim expels the object or becomes unresponsive.
If the person becomes unconscious, perform standard cardiopulmonary resuscitation (CPR) with chest compressions and rescue
breaths.

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 After choking stops, seek medical attention for the client.

View the “Skills Checklist: Choking Maneuver” with an associated video of performing the Heimlich maneuver.

1. This work is a derivative of Nursing Pharmacology by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. “A man having a Heart Attack.png” by https://www.myupchar.com/en is licensed under CC BY-SA 4.0. ↵
3. TED-Ed. (2017, February 14). What happens during a heart attack? - Krishna Sudhir [Video]. YouTube. All rights reserved.
https://youtu.be/3_PYnWVoUzM ↵
4. “Stroke Diagram” by ConstructionDealMkting is licensed under CC BY 2.0 ↵
5. Centers for Disease Control and Prevention. (2020, August 28). Stroke. https://www.cdc.gov/stroke/signs_symptoms.htm ↵
6. Centers for Disease Control and Prevention (CDC). (2015, October, 26). Recognize the Signs and Symptoms of Stroke. [Video].
YouTube. All rights reserved. https://youtu.be/cx5G1VdC9UA ↵
7. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures ↵
8. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures ↵
9. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures ↵
10. Epilepsy Foundation. (2020). Types of seizures. https://www.epilepsy.com/learn/types-seizures ↵
11. Epilepsy Foundation. (2016, November 16). Wendy says #ShareMySeizure (30 sec) [Video]. YouTube. All rights reserved.
https://youtu.be/KYQXSam1kww ↵
12. Epilepsy Foundation. (2015, November 17). Responding to seizures: Care and comfort first aid [Video]. YouTube. All rights
reserved. https://youtu.be/PAl9LDq9yas ↵
13. MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US). Stroke signs and symptoms; [reviewed 2020, Aug
28; cited 2021, Dec 3]. https://medlineplus.gov/lab-tests/fall-risk-assessment/ ↵
14. “RACE-Safety--Arvin61r58.png” by unknown at Freesvg.org is licensed under CC0 1.0 ↵
15. UCSD Visual Media Group. (2019, January 18). RACE + PASS training [Video]. YouTube. All rights reserved.
https://youtu.be/pVHFdEivyNE ↵
16. National Safety Council. (n.d.). Choking prevention and rescue tips. https://www.nsc.org/home-safety/safety-topics/choking-
suffocation ↵
17. “Heimlich_Adult_%26_Child.png” by BruceBlaus is licensed under CC BY-SA 4.0 ↵
18. National Safety Council. (n.d.). Choking prevention and rescue tips. https://www.nsc.org/home-safety/safety-topics/choking-
suffocation ↵

This page titled 3.2: Emergency Situations is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra Sandquist
Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request.

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3.3: Resident Environment
When an individual moves into a nursing home, it can be a complicated, stressful, and sometimes confusing time for them and their
loved ones. Because nurse aides spend more time with residents than any other staff member, your actions are critical to help ease
their worries associated with a change in their environment.

 Reflective Activity

Reflect about a time when you moved, changed schools, started a new job, or went to a new place on your own. What things
made you feel more comfortable during those transitions? Applying how you felt during those experiences can help you
empathize with and provide peace of mind for anyone experiencing a transition.

In addition to experiencing a new environment, newly admitted residents have also typically had a recent major change in cognitive
or physical functioning. They are adjusting to not only a new environment but also to how they feel, think, and move. Actions that
were previously taken for granted, such as walking, eating, and performing self-care, now require assistance from others. Review
the activity in the Chapter 1 subsection “Managing Clients’ and Family Members’ Stress” to increase your awareness of factors
that may affect a resident’s outlook and the ways you can improve their quality of life.
As a nurse aide, you can be a major factor in promoting better outcomes for residents by making observations related to their
nutritional intake, physical activity, and psychosocial well-being and communicating these observations to the nurse. The Fulmer
SPICES tool is a good framework for promoting health in the older adult population. SPICES is an acronym that stands for
observing the following aspects that can affect well-being for older adults: Sleep, Problems eating, Incontinence, Confusion,
[1]
Evidence of falls, and Skin Breakdown :
Sleep: Older adults need 7-9 hours of sleep per day. To promote good sleep, control environmental factors such as noise,
lighting, and temperature. Report sleep disturbances such as excessive snoring or gasping for air or if the resident states they
[2]
don’t feel rested on awakening.
Problems Eating: Report issues with chewing and swallowing during meals, as well as residents’ food preferences. Insufficient
nutritional intake can lead to skin breakdown issues, infection, and an overall decline in function. More information about
eating problems can be found in Chapter 5.
Incontinence: Incontinence is a lack of voluntary control over urination or defecation. Offer toileting to your residents at least
every two hours and on their request. Check incontinence products at least every two hours, especially for those residents with
communication problems. More information about incontinence can be found in Chapter 5.
Confusion: Report any new onset of confusion because it can be a sign of infection. An example of a resident with new
confusion would be not knowing the day of the week or where they are when normally they are aware and oriented.
Evidence of Falls: Report any new weakness or difficulty in transferring from bed to wheelchair or a change in the ability to
walk. Read more about fall prevention in the “Emergency Situations” section of this chapter and in Chapter 9.
Skin Breakdown: Damage to the skin is called skin breakdown. Common preventable causes of skin breakdown are
immobility and incontinence. For residents who are unable to independently move, reposition them at least every two hours. For
residents with incontinence, provide proper hygiene to keep their skin clean and dry. More information about skin breakdown
can be found in Chapter 5.

Transitioning to a New Environment

Transitioning to a nursing home environment involves an abrupt change to an individual’s living environment in terms of privacy,
[3]
size, and personal belongings. See an image of a typical shared room in a nursing home in Figure 3.5. In addition to this change in
environment, residents often cannot follow their typical schedule they had at home, although accommodations should be made to
meet their preferences as much as possible.

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 Figure 3.5 Typical Resident Environment in a Nursing Home
Nurse aids help residents transition to a new environment. When a new admission is expected, a staff member should be at the
entry area to greet the individual and their loved ones. The room should be prepared before arrival, which includes sanitization
procedures and making the bed. Read more about how to make a hospital bed in the “Skills Checklist” section of this chapter.
Actions to help residents transition to their new environment include the following:
Introduce the resident to the staff and identify who is responsible for which resident care needs, such as CNAs, dietary aides,
activities personnel, nurses, etc.
Provide a tour of the facility.
Show the resident where they can find the daily schedule of events and activities.
Assist the resident in organizing their belongings and arranging their room to fit their needs and preferences.
Introduce their roommate if they are sharing a room.
If possible, arrange to have a resident mentor. A resident mentor is another resident who can answer questions and encourage
interaction.
Every facility has their own admission procedures, but a common requirement is the completion of a written inventory of the
resident’s belongings. This inventory is typically done by the nurse aide depending upon the care setting. See an example of a
[4]
Resident Personal Belongings Inventory used in an adult family home in Figure 3.6.

Figure 3.6 Sample Resident Belonging Inventory

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 1. Aronow, H. U., Borenstein, J., Haus, F., Braunstein, G. D., & Bolton, L. B. (2014). Validating SPICES as a screening tool for
frailty risks among hospitalized older adults. Nursing Research and Practice, 2014, 846759.
https://doi.org/10.1155/2014/846759 ↵
2. Centers for Disease Control and Prevention. (2017, March 2). How much sleep do I need?
https://www.cdc.gov/sleep/about_sleep/how_much_sleep.html ↵
3. “residentroom.jpg” by unknown for Stratford Manor. Image used under Fair Use. Access for free at https://stratfordrehab.com/
↵
4. “Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)” by Washington State Department of
Social and Health Services is in the Public Domain. Access for free at https://www.dshs.wa.gov/office-of-the-secretary/forms ↵

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Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request.

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3.4: Body Mechanics and Safe Equipment Use
In addition to promoting safety for patients and their families, it is important for health care workers to be aware of safety risks in
the environment and to take measures to protect themselves. Common safety risks to health care workers include sharps injuries,
exposure to blood-borne pathogens, lack of personal protective equipment, and lifting injuries. A sharps injury is a penetrating
wound from a needle, scalpel, or other sharp object that may result in exposure to blood-borne pathogens. Blood-borne pathogens
are pathogenic microorganisms present in blood and body fluids that can cause disease such as hepatitis B (HBV) and human
immunodeficiency virus (HIV). Personal protective equipment (PPE) is used to prevent transmission of blood-borne pathogens
and infection and includes gloves, masks, goggles, gowns, and other types of protective equipment. This section will focus on
lifting injuries related to moving clients, and the other safety risks will be discussed in Chapter 4.
The health and well-being of nurse aides is directly related to the quality of care residents receive. When a health care worker is
injured, they may be unable to provide care to the extent required by residents. With this in mind, it is vital for nursing assistants to
know how to prevent injury in the workplace. An article published in the 2018 International Journal of Environmental Research
and Public Health noted that 88% of nurse aides reported at least one of their body parts having a work-related musculoskeletal
[1]
symptoms (WRMS). The lower back was the most commonly affected WRMS area, followed by the arms and shoulders.
According to this study, nursing assistants ranked first for occupational-related back sprains and strains, above construction
workers, garbage collectors, and other health care workers. WRMS reported by nurse aides account for over 50% of all
musculoskeletal injuries reported in the United States. These injuries are attributed to manual handling of clients, lifting heavy
[2]
physical loads, assuming frequent awkward positions, and performing repetitive movements.
Using gait belts and mechanical lifts for transferring residents from one location to another, such as from the bed to a wheelchair or
a wheelchair to the toilet, has greatly reduced the risk of lifting injuries to both residents and aides. These transferring techniques
will be discussed in Chapter 8.
Lifting injuries can also occur when repositioning residents while they are in bed. Repositioning is frequently performed for
residents to provide hygiene, alleviate pain, or prevent skin breakdown. The ABC mnemonic for using proper body mechanics
[3]
when transferring or repositioning residents stands for Alignment, Base of support, and Center of gravity :
Alignment: Correct body alignment is also referred to as good posture. When standing up straight, an imaginary line should be
able to be drawn straight down through the center of the body so that both sides of the body are mirror images of each other.
Body parts should be lined up naturally, with arms at one’s side, palms directed forward, and feet pointed forward and slightly
apart. Follow these guidelines to use proper alignment to prevent lifting injuries:
Maintain correct body alignment when lifting or carrying an object.
Keep the object close to your body, unless close proximity could transmit pathogens.
Point your feet and body in the direction you are moving.
Do not twist at the waist.
Base of support: Creating a good base of support improves your balance, whereas imbalance creates awkward positioning that
can lead to injury. To create a strong base of support, place your feet about shoulder width apart or just slightly wider than your
hips.
Center of gravity: A person’s center of gravity is where most of one’s weight is concentrated. When standing, the pelvis is the
center of gravity. Maintaining a low center of gravity provides a stable base of support and improves balance.
For example, when lifting objects or people, keep your center of gravity low with a good base of support by bending at the knees
with the feet shoulder width apart. Keep in mind that your center of gravity also includes the resident or the object, so keep them as
close to your body as possible. To maintain good alignment, face the person or object you are moving and use both sides of your
[4]
body equally. Figure 3.7 illustrates safer body mechanics in Option “C” by maintaining good alignment, establishing a base of
support, and keeping the load close and near to one’s center of gravity while bending the knees.

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 Figure 3.7 Center of Gravity
Facilities have specialized equipment used to assist in lifting and transferring clients that significantly reduces the risk of lifting
injuries. Manufacturers provide specific instructions for the safe use and maintenance of their equipment. Be certain that you
receive extensive training on safely using this equipment during your orientation to the facility. Orientation to lifting equipment
should include becoming familiar with all parts of the device, the requirements for the mobility status of residents who will use that
[5]
device, and potential risks to residents and caregivers while using the device. See Figure 3.8 for an image of lifting equipment.

Figure 3.8 Lifting Equipment

For additional information on OSHA regulations for using lifting equipment and preventing lifting injuries, refer to this
document: Guidelines for Nursing Homes PDF.

1. Cheung, K., Szeto, G., Lai, G., & Ching, S. (2018). Prevalence of and factors associated with work-related musculoskeletal
symptoms in nursing assistants working in nursing homes. International Journal of Environmental Research and Public Health,
15(2), 265. https://doi.org/10.3390/ijerph15020265 ↵
2. Cheung, K., Szeto, G., Lai, G., & Ching, S. (2018). Prevalence of and factors associated with work-related musculoskeletal
symptoms in nursing assistants working in nursing homes. International Journal of Environmental Research and Public Health,
15(2), 265. https://doi.org/10.3390/ijerph15020265 ↵
3. North Carolina Department of Health and Human Services. (2019). State-approved curriculum: Nurse aide I Training program.
https://info.ncdhhs.gov/dhsr/hcpr/curriculum/pdf/moduleI.pdf ↵
4. “Centre_of_Gravity.png” by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under CC BY 4.0. Access for free at
https://opentextbc.ca/clinicalskills/chapter/3-2-body-mechanics/ ↵
5. “User-Integra-lifter1.jpg” by Integracp is licensed under CC BY-SA 3.0 ↵

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Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available
upon request.

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3.5: Skills Checklist- Making an Unoccupied Bed Checklist
Bed making is a necessary skill for nursing assistants to keep the environment clean, prevent skin breakdown and the spread of
infection, and respect the resident’s dignity by providing an orderly environment. Linens should be changed at least weekly or
whenever they become soiled.
Follow these infection control guidelines when making beds:
Never allow linens to touch your uniform.
Do not transfer linens from one room to another.
Do not place soiled linens on the floor.
If linens touch the floor, they should be placed in the soiled laundry for cleaning and not used.
Do not shake linens because it can spread airborne pathogens.
Store clean linens in a closed closet or a covered cart.
Making an Unoccupied Bed Checklist
1. Gather Supplies: Linens
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Place a clean barrier on a flat surface. Flip the linens over and place them on the barrier so the fitted sheet is on top.
Don gloves.
Look for any personal belongings that may have been left in the bed and return them to their proper place.
Untuck the corners and roll all linens together to the middle of the bed.
Place soiled linens in a linen bag or other appropriate container according to facility policy.
Remove gloves.
Perform hand hygiene.
If the bed is soiled, sanitize it or notify environmental services to sanitize it.
After the bed has dried from sanitization, place the fitted sheet on the bed. Seams should be against the mattress and away
from the resident. Smooth the sheet to prevent wrinkles that can cause injury to fragile skin. (Note: If a flat sheet is used as
the bottom sheet, refer to sub-bullets below for details on making mitered corners.)
Place the lift sheet where it is estimated the resident’s shoulders to hips will be when they are in bed.
Place a soaker pad or other waterproof barrier on top of the lift sheet.
Place the flat sheet on top and smooth it out. Make mitered corners at the foot of the bed by doing the following:
Tuck the entire end of the sheet under the foot of the bed.
While facing the foot of the bed, create a 45-degree angle from the corner of the bed with the sheet.
Place the angled edge of the sheet on top of the bed and tuck in anything hanging below the bed frame.
Lower the angled sheet back over the edge of the bed.
Place a bedspread or blanket on top of the sheet per the resident’s preference. Make a mitered corner in the bedspread or
blanket by performing the steps above.
Lay a pillow on the bed and slide the pillowcase over the pillow.
Put the pillow at the head of the bed with the open end of the pillowcase faced away from the door. Repeat for multiple
pillows.
4. Post-Procedure Steps:
Perform hand hygiene.
Check on resident comfort and ask if anything else is needed.

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 Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Report abnormal findings to the nurse.

[1]
View a YouTube video of a nursing instructor demonstrating making an unoccupied bed:

Making an Unoccupied Bed

1. Chippewa Valley Technical College. (2022, December 3). Making an Unoccupied Bed. [Video]. YouTube. Video licensed under
CC BY 4.0. https://youtu.be/K0c9fSd46JA ↵

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and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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3.6: Skills Checklist- Making an Occupied Bed
Bed making is a necessary skill for nursing assistants to keep the environment clean, prevent skin breakdown and the spread of
infection, and respect the resident’s dignity by providing an orderly environment. Linens should be changed at least weekly or
whenever they become soiled.
Follow these infection control guidelines when making beds:
Never allow linens to touch your uniform.
Do not transfer linens from one room to another.
Do not place soiled linens on the floor.
If clean linens touch the floor, they should be placed in the soiled laundry for cleaning and not used.
Do not shake linens because it can spread airborne pathogens.
Store clean linens in a closed closet or a covered cart.
Making an Occupied Bed Checklist
1. Gather Supplies: Linens
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Place a clean barrier on a flat surface, flip linens over, and place them on the barrier so the fitted sheet is on top.
Don gloves.
Look for any personal belongings that may have been left in the bed and return them to their proper place.
Put the side rail up.
Move to the opposite side of the bed.
Using the lift sheet, roll the resident towards the side rail.
Begin rolling soiled linens to the middle of the bed and under the resident.
Remove gloves.
Perform hand hygiene.
Place a fitted sheet on the half of the bed you are working on.
Place the lift sheet and soaker pad in the same manner, fan folding them under the resident.
Raise the side rail.
Move to the opposite side of the bed.
Put on gloves.
Lower side rail on working side of the bed.
Roll the resident to the opposite side.
Remove the soiled linens and place them in a linen bag.
Remove gloves.
Perform hand hygiene.
Pull through the fitted sheet, lift sheet, and soaker pad, ensuring there are no wrinkles.
Assist the resident to a supine position.
Keeping the resident covered, place a new flat sheet on top of them.
Make mitered corners at the foot of the bed by doing the following:
Tuck the entire end of the sheet under the foot of the bed.
Facing the foot of the bed, create a 45-degree angle from the corner of the bed with the sheet.
Place the angled sheet on top of the bed and tuck in anything hanging below the bed frame.
Lower the angled sheet over the edge of the bed.

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 Put a clean pillowcase on a new pillow and exchange it for the soiled pillow. Put the pillow at the head of the bed with the
open end of the pillowcase faced away from the door. Repeat for multiple pillows.
Repeat steps for any blankets or bedspreads.
Make a toe pleat (i.e., a pleat in the sheet which allows an individual to move feet) to prevent pressure.
4. Post-Procedure Steps:
Perform hand hygiene.
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Report abnormal findings to the nurse.
View a YouTube video[1] of a nursing instructor demonstrating making an occupied bed:
One or more interactive elements has been excluded from this version of the text. You can view them online here:
https://wtcs.pressbooks.pub/nurseassist/?p=1920#oembed-1

1. Chippewa Valley Technical College. (2022, December 3). Making an Occupied Bed. [Video]. YouTube. Video licensed under
CC BY 4.0. https://youtu.be/AN9pvC499P4 ↵

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available upon request.

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3.7: Learning Activities

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3.8: III Glossary
Ambulating: Walking.
Angina: Sudden chest pain beneath the sternum (breastbone) associated with a heart attack (myocardial infarction), often radiating
down the left arm in male patients.
Assistive devices: Devices such as gait belts and walkers that are used when moving a patient.
Blood-borne pathogens: Pathogenic microorganisms present in blood and body fluids that can cause disease such as hepatitis B
(HBV) and human immunodeficiency virus (HIV).
Cardiac arrhythmias: Irregularities in a person’s heart rate and/or rhythm.
Cerebrovascular attack (CVA): The medical term for what is commonly referred to as a “stroke,” caused by a lack of blood flow
and oxygen to the brain.
FAST: An acronym used to remember the early signs of a stroke: Facial drooping, Arm weakness, Slurred speech, and Time
(meaning the quicker the response, the better the outcome).
Heimlich maneuver: A procedure used for someone who is choking that uses abdominal thrusts to clear the airway so they can
breathe.
Incontinence: A lack of voluntary control over urination or defecation.
Myocardial infarction (MI): The medical term for what is commonly referred to as a “heart attack,” caused by a lack of blood
flow and oxygen to the heart.
Nonskid footwear: Shoes or socks with rubberized soles used to prevent falls.
PASS: An acronym for using a fire extinguisher that stands for the following:
P: Pull the pin on the fire extinguisher.
A: Aim the extinguisher nozzle at the base of the fire.
S: Squeeze or press the handle.
S: Sweep from side to side at the base of the flame until the fire appears to be out.
Personal protective equipment (PPE): Equipment used to prevent transmission of blood-borne pathogens and infection,
including gloves, masks, goggles, gowns, and other types of protective equipment.
RACE: An acronym for responding to a fire that stands for the following:
R: Rescue anyone in immediate danger from the fire if it doesn’t endanger your life.
A: Activate the alarm by pulling the nearest fire alarm or calling 911.
C: Contain the fire by closing all doors and windows.
E: Extinguish the fire if it is small enough using a fire extinguisher and the PASS method. Evacuate patients and oneself if the
fire cannot be extinguished.
Resident mentor: A resident who can answer questions and encourage interaction for a new resident recently admitted to a long-
term care facility.
Seizure: A transient occurrence of signs and/or symptoms due to abnormal neuronal activity in the brain.
Sharps injury: A penetrating wound from a needle, scalpel, or other sharp object that may result in exposure to blood-borne
pathogens.
Shortness of breath (SOB): Difficulty breathing or a feeling of not being able to catch one’s breath.
Skin breakdown: Damage to the skin due to common preventable causes like immobility and incontinence.
SPICES: An acronym that stands for observing the following aspects of well-being for older adults: Sleep, Problems eating,
Incontinence, Confusion, Evidence of falls, and Skin breakdown.
Thrombolytic medication: Medication (such as tPA) used to dissolve clots in arteries.

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Transient ischemic attack (TIA): A medical term for what is commonly referred to as a ministroke. A TIA is a temporary period
of symptoms similar to those of a stroke that usually last only a few minutes and don’t cause permanent brain damage.
Work-related musculoskeletal symptoms (WRMS): Symptoms from musculoskeletal injuries experienced at work, such as
lower back pain, that are attributed to manual handling of clients, heavy physical loads, frequent awkward positions, and repetitive
movements.

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 CHAPTER OVERVIEW

4: Adhere to Principles of Infection Control

4.1: Introduction to Adhere to Principles of Infection Control
4.2: Chain of Infection
4.3: Defenses Against Transmission of Infection
4.4: Precautions Used to Prevent the Spread of Infection
4.5: Personal Protective Equipment (PPE)
4.6: Blood-borne Pathogen Standard
4.7: Signs and Symptoms of Infection
4.8: Skills Checklist- Hand Hygiene With Soap and Water
4.9: Skills Checklist- Hand Hygiene With Alcohol-Based Hand Sanitizer
4.10: Skills Checklist- Removing Gloves
4.11: Skills Checklist- Donning/Doffing PPE Without a Mask
4.12: Skills Checklist- Donning/Doffing PPE With a Mask and Face Shield or Goggles
4.13: Learning Activities
4.14: IV Glossary

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upon request.

1
4.1: Introduction to Adhere to Principles of Infection Control
Learning Objectives
Discuss principles of medical asepsis for client and personal safety
Describe methods to prevent blood-borne pathogen transmission
Apply principles of standard and transmission-based precautions and infection prevention

[1]
Infection control, also called infection prevention, prevents or stops the spread of infections in health care settings. Facilities hire
licensed health professionals who are in charge of infection prevention, but everyone is responsible for reducing the spread of
infection. This chapter will discuss the manner in which infections spread, common signs and symptoms of infection, and infection
control basics, including methods to protect you and those you care for from infection.

1. Centers for Disease Control and Prevention. (2020, April 29). Infection control.
https://www.cdc.gov/infectioncontrol/index.html ↵

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history is available upon request.

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4.2: Chain of Infection
The chain of infection, also referred to as the chain of transmission, describes how an infection spreads based on these six links of
transmission:
Infectious Agent
Reservoirs
Portal of Exit
Modes of Transmission
Portal of Entry
Susceptible Host
[1]
See Figure 4.1 for an illustration of the chain of infection. If any “link” in the chain of infection is removed or neutralized,
transmission of infection will not occur. Health care workers must understand how an infectious agent spreads via the chain of
transmission so they can break the chain and prevent the transmission of infectious disease. Routine hygienic practices, standard
precautions, and transmission-based precautions are used to break the chain of transmission.

Figure 4.1 Chain of Infection

The links in the chain of infection include Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, and
[2]
Susceptible Host :
Infectious Agent: Microorganisms, such as bacteria, viruses, fungi, or parasites, that can cause infectious disease.
Reservoir: The host in which infectious agents live, grow, and multiply. Humans, animals, and the environment can be
reservoirs. Examples of reservoirs are a person with a common cold, a dog with rabies, or standing water with bacteria.
Sometimes a person may carry an infectious agent but is not symptomatic or ill. This is referred to as being colonized, and the
person is referred to as a carrier. For example, many health care workers carry methicillin-resistant Staphylococcus aureus
(MRSA) bacteria in their noses but are not symptomatic.
Portal of Exit: The route by which an infectious agent escapes or leaves the reservoir. In humans, the portal of exit is typically
a mucous membrane or other opening in the skin. For example, pathogens that cause respiratory diseases usually escape
through a person’s nose or mouth.
Mode of Transmission: The way in which an infectious agent travels to other people and places because they cannot travel on
their own. Modes of transmission include contact, droplet, or airborne transmission. For example, touching sheets with drainage
from one person’s infected wound and then touching another person without washing one’s hands is an example of contact
transmission of an infectious agent. Examples of droplet or airborne transmission are coughing and sneezing, depending on the
size of the microorganism.
Portal of Entry: The route by which an infectious agent enters a new host (i.e., the reverse of the portal of exit). For example,
mucous membranes, skin breakdown, and artificial openings in the skin created for the insertion of medical equipment (such as
intravenous lines) are at high risk for infection because they provide an open path for microorganisms to enter the body. Tubes
inserted into mucous membranes, such as a urinary catheter, also facilitate the entrance of microorganisms into the body. A
person’s immune system fights against infectious organisms that have entered the body through the use of nonspecific and

4.2.1 https://med.libretexts.org/@go/page/70315
 specific defenses. Read more about defenses against microorganisms in the “Defenses Against Transmission of Infection”
section of this chapter.
Susceptible Host: A person at elevated risk for developing an infection when exposed to an infectious agent due to changes in
their immune system defenses. For example, infants (up to 2 years old) and older adults (aged 65 or older) are at higher risk for
developing infections due to underdeveloped or weakened immune systems. Additionally, anyone with chronic medical
conditions (such as diabetes) are also at higher risk of developing an infection. In health care settings, almost every patient is
considered a “susceptible host” because of preexisting illnesses, medical treatments, medical devices, or medications that
increase their vulnerability to developing an infection when exposed to infectious agents in the health care environment. As
caregivers, it is the NA’s responsibility to protect susceptible patients by breaking the chain of infection.
After a susceptible host becomes infected, they become a reservoir that can then transmit the infectious agent to another person. If
an individual’s immune system successfully fights off the infectious agent, they may not develop an infection, but instead the
person may become an asymptomatic “carrier” who can spread the infectious agent to another susceptible host. For example,
individuals exposed to COVID-19 may not develop an active respiratory infection but can spread the virus to other susceptible
hosts via sneezing.
Learn more about the chain of infection by expanding the element descriptors below.
This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise
noted.
This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise
noted.
This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise
noted.

This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise
noted.
This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise
noted.
This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise
noted.

Putting It All Together

Note: To enlarge the print, you can expand the activity by clicking the arrows in the right upper corner of the text box. Please drag
and drop the descriptors and actions into the appropriate boxes to demonstrate the various steps in the chain of infection.
This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise
noted.

Healthcare-Acquired Infections
An infection that develops in an individual after being admitted to a health care facility or undergoing a medical procedure is a
healthcare-associated infection (HAI), formerly referred to as a nosocomial infection. About 1 in 31 hospital patients develops at
least one healthcare-associated infection every day. HAIs increase the cost of care and delay recovery. They are associated with
permanent disability, loss of wages, and even death. An example of an HAI is a skin infection that develops in a patient’s incision
[3] [4]
after they had surgery due to improper hand hygiene of health care workers. , It is important to understand the dangers of
Healthcare-Acquired Infections and actions that can be taken to prevent them.

Read more details about healthcare-acquired infections in the “Infection” chapter of Open RN Nursing Fundamentals.

Healthcare-Associated Infections by Michelle Hughes is licensed under CC BY 4.0.

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 1. “Chain-of-Transmission” by unknown author is licensed under CC BY-NC 4.0. Access for free at
https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/40/ ↵
2. Department of Health. (n.d.). Chain of infection in infection prevention and control (IPAC). The Government of Nunavut.
https://www.gov.nu.ca/health/information/infection-prevention-and-control ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health &
Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html ↵

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4.3: Defenses Against Transmission of Infection
The body tries to protect itself from infectious agents by using specific and nonspecific defenses. Specific defenses are immune
system processes that include white blood cells attacking particular pathogens. Nonspecific defenses are generic barriers that
prevent pathogens from entering the body, including physical, mechanical, or chemical barriers.

Physical Defenses
Physical defenses are the body’s most basic form of defenses against infection. Physical defenses include barriers such as skin and
[1]
mucous membranes, as well as mechanical defenses, that physically remove microbes from areas of the body.

Skin
One of the body’s most important physical barriers is the skin barrier that is composed of three layers of closely packed cells. See
[2]
Figure 4.2 for an illustration of layers of the skin. The topmost layer of skin, called the epidermis, consists of cells that are packed
with keratin. Keratin makes the skin’s surface mechanically tough and resists degradation by bacteria. When the skin barrier
[3]
becomes broken, such as becoming cracked from dryness, microorganisms can enter and cause infection.

Figure 4.2 Skin Layers

Mucous Membranes
Mucous membranes lining the nose, mouth, lungs, and urinary and digestive tracts provide another nonspecific barrier against
pathogens. Mucous is a moist, sticky substance that covers and protects the layers beneath it and also traps debris, including
[4]
microbes. Mucus secretions also contain antimicrobial agents.
In many regions of the body, mechanical actions flush mucus (along with trapped microbes) out of the body or away from potential
sites of infection. For example, in the respiratory system, inhalation can bring microbes, dust, mold spores, and other small airborne
debris into the body. This debris becomes trapped in the mucus lining the respiratory tract. The cells lining the upper parts of the
respiratory tract have hair-like appendages known as cilia. Movement of the cilia propels debris-laden mucus out and away from
the lungs. The expelled mucus is then swallowed (and destroyed in the stomach) or coughed out. However, smoking limits the
efficiency of this system, making smokers more susceptible to developing respiratory infections. Additionally, as people age, their
chest muscles weaken, and coughing becomes less productive, which also increases the risk of developing a respiratory infection.

Mechanical Defenses
In addition to physical barriers, the body has several mechanical defenses that physically remove pathogens from the body and
prevent infection. For example, the flushing action of urine carries microbes away from the body and is responsible for maintaining
a sterile environment of the urinary tract.
The eyes have additional physical barriers and mechanical mechanisms for preventing infections. Eyelashes and eyelids are
physical barriers that prevent dust and airborne microorganisms from reaching the surface of the eye. Any microbes or debris that
make it past these physical barriers are flushed out by the mechanical action of blinking. Blinking bathes the eye in tears and
[5] [6]
washes debris away. See Figure 4.3 for an example of eyelashes as a mechanical defense.

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 Figure 4.3 Eyelashes Are a Mechanical Defense Against Pathogens

Chemical Defenses
In addition to physical and mechanical defenses, our immune system uses several chemical defenses that inhibit microbial invaders.
The term chemical mediators refers to a wide array of substances found in various fluids and tissues throughout the body. For
example, sebaceous glands in the dermis secrete an oil called sebum that is released onto the skin surface through hair follicles.
Sebum provides an additional layer of defense by helping seal off the pore of the hair follicle and preventing bacteria on the skin’s
surface from invading sweat glands and surrounding tissue. However, environmental factors can affect these chemical defenses of
the skin. For example, low humidity in the winter dries the skin and makes it more susceptible to pathogens that are normally
inhibited by the skin’s low pH. Application of skin moisturizer restores moisture and essential oils to the skin and helps prevent dry
[7]
skin from becoming infected.
Other types of chemical defenses are pH levels, chemical mediators, and enzymes. For example, in the urinary tract, the slight
acidity of urine inhibits the growth of potential pathogens in the urinary tract. The respiratory tract has various chemical mediators
in the nasal passages, trachea, and lungs that have antibacterial properties. Enzymes in the digestive tract eliminate most
microorganisms that survive the acidic environment of the stomach. However, feces, the end product of the digestive system, can
still contain some microorganisms. For this reason, hand hygiene is vital after using the restroom or assisting a client with perineal
[8]
care to prevent the spread of infection.

1. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/microbiology/pages/1-introduction ↵
2. “OSC_Microbio_17_02_Skin.jpg” by OpenStax is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/microbiology/pages/17-1-physical-defenses ↵
3. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/microbiology/pages/1-introduction ↵
4. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/microbiology/pages/1-introduction ↵
5. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/microbiology/pages/1-introduction ↵
6. “Eyelashes_of_a_2-month-old_baby_boy.png” by Karthik.yerramilly is licensed under CC BY-SA 4.0 ↵
7. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at
https://openstax.org/books/microbiology/pages/1-introduction ↵
8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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4.4: Precautions Used to Prevent the Spread of Infection
Health care agencies use several methods to prevent the spread of infection: standard precautions and transmission-based
precautions.

Standard Precautions
Standard precautions are used by health care workers during client care when contact or potential contact with blood or body
fluids may occur. Standard precautions should also be used when assisting a client with activities of daily living (ADLs) and using
water, soap, or lotion. Standard precautions are based on the principle that all blood, body fluids (except sweat), nonintact skin, and
mucous membranes may contain transmissible infectious agents. These precautions reduce the risk of exposure for the health care
[1]
worker and protect patients from potential transmission of infectious organisms.
[2]
According to the Centers for Disease Control and Prevention (CDC), standard precautions include the following :
Using proper hand hygiene at the appropriate times
Using personal protective equipment (e.g., gloves, gowns, masks, eyewear) whenever exposure to infectious agents may occur
Implementing respiratory hygiene for staff, patients, and visitors
Proper cleaning and sanitizing of the environment, equipment, and devices
Handling laundry safely
Using transmission-based precautions when indicated

Hand Hygiene
The easiest and most effective way to break the chain of infection is by using proper hand hygiene at appropriate times during
patient care. Knowing when to wash your hands, how to properly wash your hands, and when to use soap and water or hand
sanitizer are vital for reducing the spread of infection and keeping yourself healthy. Hand hygiene is the process of removing,
killing, or destroying microorganisms or visible contaminants from the hands. There are two hand-hygiene techniques:
handwashing with soap and water and the use of alcohol-based hand rub (ABHR), also referred to as hand hygiene gel or hand
[3]
sanitizer.
Health care providers’ hands are the most common mode of transmission of microorganisms. As a nursing assistant, your hands
will touch many people and objects when providing care. When you touch a client, their personal items, medical equipment, or
their surrounding environment, you can indirectly transmit microorganisms to the client, another client, yourself, equipment, or a
new environment. Microorganisms can easily be transferred from your hands to others or objects in the health care setting if proper
[4]
hand hygiene practices are not followed. Consistent and effective hand hygiene is vital for breaking the chain of transmission.
[5]
It is essential for all health care workers to use proper hand hygiene during specific moments of patient care :
Immediately before touching a patient
Before performing an aseptic task, such as emptying urine from a Foley catheter bag
Before moving from a soiled body site to a clean body site
After touching a patient or their immediate environment
After contact with blood, body fluids, or contaminated surfaces (with or without gloves)
Immediately after glove removal
[6]
See Figure 4.4 for an illustration of the five moments of hand hygiene.

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 Figure 4.4 Moments of Hand Hygiene
Hand hygiene also includes health care workers keeping their nails short with tips less than 0.5 inches and no nail polish. Nails
should be natural, and artificial nails or tips should not be worn. Artificial nails and chipped nail polish have been associated with a
[7]
higher level of pathogens carried on the hands of health care workers despite using proper hand hygiene.
Review the Moments of Hand Hygiene by clicking on the interactive activity below.
This work is a derivative of Your 4 Moments for Hand Hygiene by Michelle Hughes and is licensed under CC BY 4.0.
Proper hand hygiene includes handwashing with soap and water or the use of alcohol-based hand rub. Both procedures are
described in the following sections.
Handwashing With Soap and Water
Handwashing involves the use of soap and water to physically remove microorganisms from one’s hands. Certain health care
situations require handwashing with soap and water instead of using alcohol-based hand rub (ABHR). For example, hands must be
washed with soap and water if they are visibly soiled, have been exposed to blood or body fluids, or have been exposed to
norovirus, C. difficile, or Bacillus anthracis. The mechanical action of lathering and scrubbing with soap for a minimum of 20
[8]
seconds is vital for removing these types of microorganisms.
Soap is required during handwashing to dissolve fatty materials and facilitate their subsequent flushing and rinsing with water.
Soap must be rubbed on all surfaces of both hands followed by thorough rinsing and drying. Water alone is not suitable for
[9]
cleaning soiled hands. The entire procedure should last 40 to 60 seconds, and soap approved by the health agency should be used.
[10]
When washing with soap and water, the Centers for Disease Control and Prevention (CDC) recommends the following steps :
Wet hands with warm or cold running water and apply facility-approved soap.
Lather hands by rubbing them together with the soap. Use the same technique as the hand rub process to clean the palms and
fingers, between the fingers, the backs of the hands and fingers, the fingertips, and the thumbs.
Scrub thoroughly for at least 20 seconds.
Rinse hands well under clean, running water.
Dry the hands, using a clean towel or disposable toweling, from fingers to wrists.
Use a clean paper towel to shut off the faucet.
[11]
See Figure 4.5 for an illustration of handwashing with soap and water.

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 Figure 4.5 How to Handwash with Soap and Water
See the “Skills Checklist: Hand Hygiene With Soap and Water” section later in this chapter for a checklist of steps and an
associated demonstration video of this procedure. Common safety considerations and errors when washing hands are described in
the following box.

[12]
Safety Considerations
Always wash hands with soap and water if hands are visibly soiled.
When working with clients where C. difficile, norovirus, or Bacillus anthracis is suspected or confirmed, soap and water
must be used. It is more effective in physically removing the C. difficile spores compared to ABHR, which is not as
effective at penetrating the spores.
Friction and rubbing are required to remove transient bacteria, oil, and debris from hands.
Always use soap and water if hands are exposed to blood, body fluids, or other body substances.
Multistep rubbing techniques using soap and water are required to promote coverage of all surfaces on hands.
[13]
Common Errors When Washing Hands With Soap and Water
Not using enough soap to cover all surfaces of the hands and wrists.
Not using friction when washing hands.

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 Not washing hands long enough. The mechanical action of lathering and scrubbing should be a minimum of 20 seconds,
and the entire procedure should last 40 to 60 seconds.
Missing areas such as the fingernails, wrists, backs of hands, and thumbs.
Not removing all soap from hands and wrists.
Shaking water off hands.
Not thoroughly drying the hands.
Drying hands from wrists to fingers or in both directions.

Practice your knowledge by clicking on this interactive learning activity.

This work is a derivative of the YouTube Hand Washing Video by Michelle Hughes and is licensed under CC BY-NC 4.0.
Alcohol-Based Hand Rub
When performing hand hygiene using the alcohol-based hand rub (ABHR) technique, a liquid, gel, or foam alcohol-based solution
is used. ABHR is the preferred method for hand hygiene when soap and water handwashing is not required. It reduces the number
of transient microorganisms on hands and is more effective for preventing healthcare-acquired infections (HAIs) caused by
Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococcus (VRE). Hand hygiene with ABHR
should be performed in front of the client prior to the beginning of care and at the end of the interaction. ABHR provided by the
[14]
agency should be used with a 70–90% alcohol concentration.
[15]
The benefits of ABHR include the following :
It kills the majority of microorganisms (including viruses) from hands.
It requires less time than soap and water handwashing.
It provides better skin tolerability and reduces skin irritation because it contains emollients.
It is easy to use and available at the point of care (i.e., where three elements of the client, the health care provider, and care
involving the client occur together).
Read safety considerations and common errors when using ABHR in the following box. See the “Skills Checklist: Hand Hygiene
With Alcohol-Based Hand Sanitizer” section later in this chapter for a checklist of steps and an associated demonstration video of
this procedure.

[16]
Safety Considerations
Do not use ABHR in combination with soap and water because it may increase skin irritation.
Use ABHR that contains emollients (oils) to help reduce skin irritation and overdrying.
Allow hands to dry completely before initiating tasks (e.g., touching the client or the environment or applying clean
gloves).
Use ABHR for all moments of hand hygiene if soap and water are not required.
DO NOT use ABHR if hands are visibly soiled, have been exposed to blood or body fluids, or the client is suspected to
have C. difficile, norovirus, or Bacillus anthracis.
Only use ABHR supplied by the facility.
[17]
Common Errors When Performing an ABHR
Not letting hands air dry (for example, rubbing one’s hands on pants to dry it off).
Shaking hands to dry.
Applying too much alcohol-based solution.
Not applying enough alcohol-based solution.
Not rubbing hands long enough (a minimum of 20 seconds) and until hands are dry.
Missing areas such as the fingernails, wrists, backs of the hands, and thumbs.

Practice your knowledge by clicking on this interactive learning activity.

This work is a derivative of Performing an Alcohol-Based Hand Rub by Michelle Hughes and is licensed under CC BY-NC 4.0.

4.4.4 https://med.libretexts.org/@go/page/70317
Respiratory Hygiene and Other Hygienic Practices
Respiratory hygiene should be used by any person with signs of illness, including cough, congestion, or increased production of
respiratory secretions to prevent the spread of infection. Respiratory hygiene refers to coughing or sneezing into the inside of one’s
elbow or covering one’s mouth/nose with a tissue when coughing and promptly disposing of used tissues. Hand hygiene should be
immediately performed after contact with one’s respiratory secretions. A coughing person should also wear a surgical mask to
[18]
contain secretions.
Additional hygiene measures are also used to prevent the spread of infection. For example, regularly changing bed linens, towels,
and hospital gowns eliminates potential reservoirs of bacteria. Gripper socks should be removed before patients get into bed to
prevent pathogens from the floor from being transferred to the patient’s bed linens.
Mobile devices should be cleaned regularly. Research has shown that cell phones and mobile devices carry many pathogens and are
dirtier than a toilet seat or the bottom of a shoe. Patients, staff, and visitors routinely bring mobile devices into health care facilities
that can cause the spread of infection. Mobile devices should be frequently wiped with disinfectant.

Disinfection and Sterilization

Disinfection and sterilization are procedures used to remove harmful pathogens from equipment and the environment to decrease
the risk of spreading infection. Disinfection is the removal of microorganisms, but it does not destroy all spores and viruses.
Sterilization destroys all pathogens on equipment or in the environment, including spores and viruses, and includes methods such
as steam, boiling water, dry heat, radiation, and chemicals. Because of the harshness of sterilization methods, skin can only be
[19]
disinfected and not sterilized.
Asepsis refers to the absence of infectious material or infection. Surgical asepsis is the absence of all microorganisms during any
type of invasive procedure, such as during surgery or heart catheterizations. Sterilization is performed on equipment used during
invasive procedures. As a nursing assistant, you may assist a registered nurse during a procedure requiring sterile technique;
however, performing sterile procedures independently is not in the scope of practice for nursing assistants.
In long-term care and other health care settings other than surgery, medical asepsis is used. Medical asepsis refers to techniques
used to prevent the transfer of microorganisms from one person or object to another but do not eliminate all microorganisms.
Nursing assistants implement medical asepsis in the following ways:
Performing hand hygiene at the appropriate moments of patient care. (See previous Figure 4.4.)
Using a barrier when placing clean linens, wash basins, and other items on a shared surface such as the countertop in a
resident’s room.
Pulling the privacy curtain when one resident has a droplet-transmitted infection to protect transmission to the other resident in
a shared room.
Cleaning equipment (such as blood pressure cuffs) between use on residents.
Starting with “cleaner” areas of the body when assisting with care and then moving to areas with higher levels of
microorganisms. For example, when bathing a client, the face is washed first, followed by the upper body and then finishing
with perineal care. (Perineal care involves washing the genital and rectal areas of the body.)

Laundry
When handling dirty linens, textiles, and patients’ clothing, follow agency policy regarding transport to prevent the potential spread
of infection. The Centers for Disease Control and Prevention (CDC) states that contaminated textiles and fabrics should be handled
with minimal agitation to avoid contamination of air, surfaces, and other individuals. They should be bagged at the point of use,
[20]
and leak-resistant bags should be used for textiles and fabrics contaminated with blood or body substances.

Transmission-Based Precautions
When providing care for individuals with known or suspected infections, additional precautions are used in addition to the
previously discussed standard precautions. Certain types of pathogens and communicable diseases are easily transmitted to others
and require additional precautions to interrupt the spread of infectious agents to health care workers and other clients. For example,
Coronavirus disease (COVID-19), C. difficile (C-diff), Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant
enterococci (VRE), Respiratory Syncytial Virus (RSV), measles, and tuberculosis (TB) require transmission-based precautions.
Transmission-based precautions (commonly referred to as isolation precautions) use specific types of personal protective
equipment (PPE) and practices based on the pathogen’s mode of transmission. It is vital for nursing assistants to understand what

4.4.5 https://med.libretexts.org/@go/page/70317
 PPE should be used in specific client care situations, which is determined by the pathogen’s mode of transmission and their
[21]
possible risk of exposure. Transmission-based precautions include three categories: contact, droplet, and airborne precautions.
Read more about each type of transmission-based precaution in Table 4.1.
[22] [23] [24]
Table 4.1 Categories of Transmission-Based Precautions , ,

Transmission-Based Precaution PPE Required Special Considerations

Used for clients with known or suspected

infections such as C-difficile (C-diff),
methicillin-resistant staphylococcus aureus
(MRSA), vancomycin resistant enterococcus
(VRE), or norovirus transmitted by touch (e.g.,
drainage from wounds or fecal incontinence).
Contact precautions should be used when there
is expected contact with the source of the
pathogen or any surfaces within the resident’s
B… Contact Gloves and gown, possibly face shield room. For example, MRSA in a client’s wound
transmits with direct contact with the wound,
so wearing gloves and a gown when entering
the room with a meal tray is typically
sufficient. However, MRSA in a client’s urine
could be accidentally splashed onto one’s
mucous membrane when emptying the bag of
an indwelling urinary catheter, so a face shield
is also necessary for this task, in addition to
wearing gloves and a gown.
Used for clients with a diagnosed or suspected
pathogen that is spread in small droplets from
sneezing or other oral and nasal secretions,
B… Droplet Gloves and a mask such as influenza or pertussis. Droplets can
travel six feet, so using barriers such as privacy
curtains and closing doors can also prevent the
spread of infection to others.
Used for clients with diagnosed or suspected
pathogens spread by very small airborne
particles from nasal and oral secretions that can
float long distances through the air, such as
measles and tuberculosis. Respirators are
specially designed masks that fit closely on the
face and filter out small particles, including the
B… Airborne Gloves and respirator
virus that causes COVID. Clients must be
placed in a room with specialized air handling
equipment found in doctors’ offices and
hospitals. Residents in long-term care settings
suspected of having an airborne illness should
be transferred immediately to prevent the
spread of infection to other residents.

Signage for Transmission-Based Precautions

When a resident has an infectious illness requiring transmission-based precautions, a sign is placed on their door and a cart of PPE
[25]
supplies is placed nearby. Signs vary by facility but look similar to the image in Figure 4.6. Due to HIPAA regulations, the type
of the pathogen and the source cannot be displayed publicly, so the sign instructs anyone wishing to enter the room to ask the nurse
first. Additional information regarding the type and source of the infection can be found in the client’s nursing care plan. After you
become aware of the pathogen, the source, and the required PPE, you can safely enter the room. If you are unsure about any aspect
of PPE required or your risk of exposure, talk to the nurse before entering the room or providing care.

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 Figure 4.6 Example of Isolation Precautions Sign

View the following YouTube video from the University of Iowa about isolation precautions in a health care setting: Standard
and Isolation Precautions.

1. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
2. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
3. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
4. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
5. Centers for Disease Control and Prevention. (2019, April 29). Hand hygiene in healthcare settings.
https://www.cdc.gov/handhygiene/ ↵
6. “5Moments_Image.gif” by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO. Access for free at
https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/ ↵
7. Blackburn, L., Acree, K., Bartley, J., DiGiannantoni, E., Renner, E., & Sinnott, L. T. (2020). Microbial growth on the nails of
direct patient care nurses wearing nail polish. Oncology Nursing Forum, 47(2), 155-164. https://doi.org/10.1188/20.onf.155-164
↵
8. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
9. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
10. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵

4.4.7 https://med.libretexts.org/@go/page/70317
11. “How_To_HandWash_Poster.pdf” by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO. Access for free at
https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/ ↵
12. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
13. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
14. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
15. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
16. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
17. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
18. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care.
https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html ↵
19. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
20. Centers for Disease Control and Prevention. (2020, April 29). Infection control.
https://www.cdc.gov/infectioncontrol/index.html ↵
21. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
22. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health &
Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html ↵
23. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by
Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
24. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019,
July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers
for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
25. “contact-precautions-sign-P.pdf” by U.S. Department of Health and Human Services and Centers for Disease Control and
Prevention is licensed in the Public Domain. Access for free at https://www.cdc.gov/infectioncontrol/basics/transmission-based-
precautions.html#anchor_1564058318 ↵

This page titled 4.4: Precautions Used to Prevent the Spread of Infection is shared under a CC BY 4.0 license and was authored, remixed, and/or
curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history
is available upon request.

4.4.8 https://med.libretexts.org/@go/page/70317
4.5: Personal Protective Equipment (PPE)
In health care settings, personal protective equipment (PPE) refers to specialized clothing or equipment used to prevent the spread of
infection, including gloves, gowns, facial protection (masks and eye protection), and respirators. PPE is a barrier that protects the health
care worker from exposure to infectious agents and also prevents the transmission of microorganisms to other individuals including
staff, patients, and visitors.

Gloves
[1]
Gloves are disposable, one-time-use coverings that protect the hands of health care providers. See Figure 4.7 for an image of nonsterile
medical gloves in various sizes in a health care setting. Gloves are used to protect the hands of a health care worker from coming into
contact with a client’s potentially infected body fluids and to protect patients from coming into contact with potential contaminants on
health care workers’ hands during certain procedures and treatments. Gloves should also be worn by a health care worker when there is
a risk of transmitting their own body fluids from nonintact skin on their hands to other individuals. However, gloves should not be worn
for routine activities such as taking vital signs or transferring a client in a wheelchair unless indicated due to transmission-based
precautions.

Figure 4.7 Gloves

Gloves are typically made from latex, nitrile, and vinyl. Many people are allergic to latex, so be sure to check for latex allergies for the
patient and other members of the health care team. Most gloves are not hand-specific and can be worn on either the left or right hand.
Gloves come in a variety of sizes such as small, medium, large, and extra large and should have a snug fit, not too tight or too loose, to
[2]
provide better protection to the health care provider.
Gloves should always be used in combination with proper hand hygiene that is performed prior to applying gloves and repeated again
after gloves are removed. Gloves are task-specific and should not be worn for more than one task or procedure on the same client
because some tasks may have a greater concentration of microorganisms than others. For example, gloves are worn to assist a client with
incontinent care, but gloves should be removed, hand hygiene performed, and new gloves applied before assisting with oral care. Gloves
should never be reused or washed to be reused. Reusing gloves has been linked with the transmission of infectious microorganisms.
[3]
Gloves should never replace hand hygiene for several reasons :
Gloves may have imperfections such as holes or cracks that are not visible.
Hands may have become contaminated while removing the gloves.
Gloves may have become damaged while wearing.
Fingernails should be short prior to applying gloves so they do not puncture the gloves. Put on (don) gloves after hands are completely
dry after performing hand hygiene. There is no specific method for putting on gloves, but care should be taken when donning gloves to
avoid tearing. Gloves should be applied so they completely cover the wrists. Gloves must be removed carefully, followed by proper
[4]
hand hygiene, to prevent the spread of infection.

Removing Gloves
[5]
See Figure 4.8 for an illustration of properly removing gloves. Hand hygiene should be performed following glove removal to ensure
the hands will not carry potentially infectious agents that might have penetrated through unrecognized tears or contaminated the hands
during glove removal.
[6]
Properly removing gloves includes the following steps :
Grasp the outside of one glove near the wrist. Do not touch your skin.
Peel the glove away from your body, pulling it inside out.

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 Hold the removed glove in your gloved hand.
Put your fingers inside the glove at the top of your wrist and peel off the second glove.
Turn the second glove inside out while pulling it away from your body, leaving the first glove inside the second.
Dispose of the gloves safely. Do not reuse.
Perform hand hygiene immediately after removing the gloves.

Figure 4.8 How to Remove Gloves to Prevent Contamination

Please review the import infection prevention and control practices described below related to glove usage.
This work is a derivative of Infection Prevention and Control Practices by Michelle Hughes and Kendra Allen is licensed under CC BY
4.0.

Isolation Gowns
Isolation gowns are protective garments worn to protect clothing from the splashing or spraying of body fluids and reduce the
transmission of microorganisms. Isolation gowns can be disposable or reusable. The gowns should have long sleeves with a snug fit at
the wrist, cover both the front and the back of the body from the neck to the thighs, and overlap at the back.
[7]
Gloves should fit over the cuffs of the gown. Gowns should fasten at the neck and waist using ties, snaps, or Velcro.
Disposable gowns are made from materials that make them resistant to fluids. Reusable gowns are made of tightly woven cotton or
polyester and are chemically finished to improve their ability to be fluid resistant; they are laundered after each use. Gowns are
considered task-specific and should be changed if they become heavily soiled or damaged. Isolation gowns should be put on
immediately prior to providing client care and should be removed immediately after care is completed before leaving the room. After
[8]
use, gowns should be discarded into an appropriate receptacle for disposal or to be laundered if the gown is reusable. See Figure 4.9
for an image of an isolation gown.

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 Figure 4.9 Isolation Gown
Special care should be taken when removing the gown to prevent contamination of clothing and skin. The front of the gown is always
considered to be contaminated. Ties at the front are considered contaminated, but ties at the side and the back are considered
[9]
uncontaminated.
See the “Donning/Doffing PPE” checklists later in this chapter for steps for proper removal of gowns. Please review the important
learning elements described below related to use of isolation gowns.
This work is a derivative of Important Considerations When Wearing Gowns by Audrey Kenmir and is licensed under CC BY 4.0.

Eye Protection
Eye protection in health care settings includes face shields, visors attached to masks, and goggles that are used to protect the eyes from
blood or body fluids. Eye protection should be worn by health care workers during patient care when there may be splashing or spraying
of body fluids or within six feet of a coughing client. For example, eye protection is worn when emptying a urinary catheter or assisting
a nurse in irrigating a wound or suctioning a client’s airway.
Eye protection can be disposable, like face shields, or reusable, like eye goggles. If eye protection is reusable, it should be cleaned
before reuse. Face shields and visors attached to masks offer better visibility than goggles. Eye protection should fit comfortably and
[10] [11]
securely while allowing for visual acuity. Eyeglasses can be worn under face shields or goggles. See Figure 4.10 for an image of eye
goggles with and without a face shield.

Figure 4.10 Eye Goggles With and Without a Face Shield

Please review the important learning elements below related to the use of eye protection.
This work is a derivative of Important Considerations When Wearing Eye Protection by Michelle Hughes and is licensed under CC BY-
NC 4.0.

Masks
Masks are protective coverings worn by health care providers to protect the mucous membranes of their nose and mouth. In long-term
care settings, masks are typically secured by elastic loops around the ears. The top edge of the mask has a bendable strip to secure the
seal of the mask over the bridge of the nose. Some situations require masks to be combined with a face shield or a visor that covers the
[12]
eyes. See Figure 4.11 for an image of masks used with eyeglasses and an eyeshield.

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 Figure 4.11. Medical Mask With and Without an Eye Shield
Medical masks should be worn when providing care that may cause splashing or spraying of blood or body fluids or within six feet of a
client who is coughing or has been placed in droplet precautions. Medical masks should also be worn by health care providers who are
coughing to prevent transmission of exhaled respiratory droplets to clients.
Medical masks can differ in their filtration effectiveness and the way in which they fit. Single-use disposable medical masks are
effective when providing care to most clients and should be changed when damp or soiled. When medical masks become moist, they
may not provide an effective barrier to microorganisms. A medical mask, when properly worn, should fit snugly over the nose, mouth,
and under the chin so that microorganisms and body fluids cannot enter or exit through the sides of the mask. If the health care worker
wears glasses, the glasses should be placed over the top edge of the mask. This will help prevent the glasses from becoming foggy as the
person wearing the mask exhales.

Removing Facemasks
Like the isolation gown, the front of the mask is considered contaminated. The mask should be removed by taking the ear loop off and
placing it in the appropriate disposal area. It is important to properly remove masks to avoid contamination. See Figure 4.12[13] for an
illustration of how to remove a facemask according to the CDC. See the “Donning/Doffing PPE With a Mask and Face Shield or
Goggles” checklist for more details.

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 Figure 4.12 Removing Facemasks
Please review the learning element/activity below for additional information on wearing medical masks.
This work is a derivative of Important Considerations When Wearing Medical Masks by Michelle Hughes and is licensed under CC BY
4.0.
This work is a derivative of Important Considerations When Wearing Medical Masks by Michelle Hughes and is licensed under CC BY
4.0.

Respirators and PAPRs

Residents requiring airborne transmission precautions are transferred to a hospital immediately upon suspicion or confirmation of an
airborne illness as respiratory protection used with airborne transmission precautions requires special equipment. Respirator masks with
N95 or higher filtration are worn by health care professionals to prevent inhalation of infectious small airborne particles. It is important
to apply, wear, and remove respirators appropriately to avoid contamination. A user-seal check should be performed by the wearer each
[14]
time a respirator is donned to minimize air leakage around the facepiece. See Figure 4.13 for CDC recommendations when wearing
disposable respirators.

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 Figure 4.13 How to Put On and Take Off a Respirator Mask
A newer piece of equipment used for respiratory protection is the powered air-purifying respirator (PAPR). A PAPR is an air-purifying
respirator that uses a blower to force air through filter cartridges or canisters into the breathing zone of the wearer. This process creates
an air flow inside either a tight-fitting facepiece or loose-fitting hood or helmet, providing a higher level of protection against
[15]
aerosolized pathogens, such as COVID-19, during respiratory suctioning. See Figure 4.14 for an example of PAPR in use.

Figure 4.14 PAPR

Resident Considerations During Isolation Precautions

There are a lot of things to consider when preventing the spread of infection among residents, staff, equipment, and surfaces. It is
important to think about the tasks you will be performing for residents and determine ahead of time what you might be exposed to in
order to select the appropriate PPE. The perspective and needs of clients placed in isolation precautions should also be considered. PPE
makes communication more difficult by hiding facial expressions and making hearing more difficult, and therapeutic touch is less

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personal when wearing gloves. Caregivers often spend less time interacting with clients in transmission-based precautions due to the
labor intensiveness of putting on and taking off PPE, resulting in clients often developing feelings of loneliness and social isolation due
to less frequent interactions. Try to keep the resident’s routine as normal as possible and apply extra effort to interact with the client.
[16]
When transporting a client with transmission-based precautions within a facility, keep these principles in mind :
Limit transport for essential purposes only, such as diagnostic and therapeutic procedures that cannot be performed in the patient’s
room.
When transporting, use appropriate barriers on the patient consistent with the route and risk of transmission. For example, for a
resident with a skin infection with MRSA, be sure the area is covered.
Notify health care personnel in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent
transmission.

1. “Surgery Centre Accriditation.jpg” by Accredia is licensed under CC BY-SA 4.0 ↵

2. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes,
Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
3. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes,
Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
4. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes,
Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
5. “poster-how-to-remove-gloves.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at
https://www.cdc.gov/vhf/ebola/resources/posters.html ↵
6. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July
22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease
Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵
7. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes,
Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
8. “U.S. Navy Doctors, Nurses and Corpsmen Treat COVID Patients in the ICU Aboard USNS Comfort (49825651378).jpg” by Navy
Medicine is in the Public Domain ↵
9. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes,
Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
10. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes,
Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 ↵
11. “IMG_2021-scaled” and “IMG_2026-scaled” by unknown author are licensed under CC BY-NC-4.0. Access for free at
https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/eye-protection/ ↵
12. “Screen-Shot-2021-05-05-at-3.57.19-PM” and “Screen-Shot-2021-05-05-at-3.57.41-PM” by unknown author are licensed under CC
BY-NC 4.0. Access for free at https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/masks/ ↵
13. “fs-facemask-dos-donts.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at
https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html ↵
14. “fs-respirator-on-off.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at
https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html ↵
15. “PAPRs_in_use_01.jpg" by Ca.garcia.s is licensed under CC BY-SA 4.0 ↵
16. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July
22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease
Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html ↵

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4.6: Blood-borne Pathogen Standard
Blood-borne pathogens are infectious microorganisms in blood and body fluids that can cause disease. These pathogens include,
but are not limited to, hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV). Workers in many health-
related occupations, including nursing assistants and other health care personnel, are at risk for exposure to blood-borne pathogens.
Needlesticks and other sharps-related injuries may expose workers to blood-borne pathogens. As a nursing assistant, your highest
risk for blood-borne exposure is during shaving and any related disposal of the razor. Typically, residents use electric razors that
have low risk of causing any open cuts, but you should always wear gloves when shaving a resident. Any disposable razor or
[1]
objects that can cause a break in the skin, such as broken glass or needles, should be disposed of in a sharps container. See Figure
[2]
4.15 for an image of a sharps container.

Figure 4.15 Sharps Container

Health care employers must follow OSHA’s guidelines for handling blood called the “Blood-borne Pathogens Standard.” If you
handle a spill of blood or body fluids, you should wear a face shield, gown, and gloves. You should receive training during your
[3]
orientation at an agency on how to properly handle a blood spill and the PPE and cleaning solutions available. See Figure 4.16 for
an image of a typical blood spill kit.

Figure 4.16 Blood Spill Kit

If you do experience an exposure to a patient’s blood or body fluids, follow agency policy and wash/flush the area and notify the
nurse supervisor. Part of OSHA’s “Blood-borne Pathogens Standard” is to complete a postexposure assessment to determine if
additional medical treatment is required. It is extremely important that this assessment occurs immediately after your exposure. The
standard also requires your employer to offer the vaccine series for hepatitis B and hepatitis C at no cost to you if you have not
previously received them.

To read more information on OSHA’s Blood-borne Pathogens Standard, visit OSHA’s FactSheet PDF.

1. Occupational Safety and Health Administration. (n.d.). Bloodborne pathogens and needlestick prevention. United States
Department of Labor. https://www.osha.gov/bloodborne-pathogens ↵
2. "Sharps Container" by Landon Cerny is licensed under CC BY 4.0 ↵
3. "Blood Spill Kit" by Landon Cerny is licensed under CC BY 4.0 ↵

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4.7: Signs and Symptoms of Infection
Nursing assistants spend a great deal of time with clients, so it is important to recognize early signs and symptoms of infection and
report them to the nurse. While there are specific symptoms associated with specific types of infection, there are some general
symptoms that can occur with all infections. These general symptoms include a feeling of malaise (i.e., a feeling of discomfort,
illness, or lack of well-being), headache, fever, and lack of appetite.
A fever is a common sign of inflammation and infection. A temperature of 38 degrees Celsius (100.4 degrees F) is generally
considered a low-grade fever, and a temperature of 38.3 degrees Celsius (101 degrees F) is considered a fever. Fever is part of the
body’s nonspecific immune response and can be beneficial in destroying pathogens. However, extremely elevated temperatures can
cause cell and organ damage, and prolonged fever can cause dehydration.
Infection raises the metabolic rate, which causes an increased heart rate. The respiratory rate may also increase as the body rids
itself of carbon dioxide created during increased metabolism. If either of these conditions are noted, they should be reported to the
nurse right away.
As an infection develops, the lymph nodes that drain that area often become enlarged and tender. The swelling indicates the lymph
nodes are fighting the infection.
If a skin infection is developing, general signs of inflammation, such as redness, warmth, swelling, and tenderness, will occur at the
site. As white blood cells migrate to the site of infection, yellow or green drainage (i.e., purulent drainage) may occur.
Some viruses, bacteria, and toxins cause gastrointestinal inflammation, resulting in loss of appetite, nausea, vomiting, and diarrhea.
See Table 4.7 for a comparison of expected findings in body systems versus unexpected findings that can indicate an infection and
require notification of the nurse and/or health care provider.
[1]
Table 4.7 Expected Versus Unexpected Findings Related to Infection

Assessment Expected Findings Unexpected Findings to Report to the Nurse

New temperature over 100.4 F or 38 C or

Vital Signs Within normal range
lower than the patient’s normal.

New confusion and/or worsening level of

Neurological Within baseline level of consciousness
consciousness.

Progressive healing of a wound with no signs New redness, warmth, tenderness, or purulent
Wound or Incision
of infection drainage from a wound.

New cough and/or productive cough of

Respiratory No cough or production of sputum
purulent sputum. New shortness of breath.

Malodorous, cloudy, or bloody urine, with

Genitourinary Urine clear and light yellow without odor increased frequency, urgency, or pain with
urination.
Loss of appetite. Nausea, vomiting, or
Good appetite and food intake; feces formed
Gastrointestinal diarrhea. Discolored or unusually malodorous
and brown
feces.
*CRITICAL CONDITIONS indicating a
possible life-threatening infection (called
sepsis) requiring immediate notification of the
nurse:
Two or more of the following criteria in a
patient with an existing infection:
Body temperature over 38 or under 36
degrees Celsius
Heart rate greater than 90 beats/minute
Respiratory rate greater than 20

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Other Considerations
The effectiveness of the immune system gradually decreases with age, making older adults more vulnerable to infection. Early
detection of infection can be challenging in older adults because they may not have a fever, but instead develop subtle changes like
new confusion or weakness that may result in a fall. The most common infections in older adults are urinary tract infections (UTI),
[2]
pneumonia, influenza, and skin infections.

1. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health &
Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html ↵
2. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health &
Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html ↵

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4.8: Skills Checklist- Hand Hygiene With Soap and Water
1. Gather/Ensure Adequate Supplies: Soap and paper towels
2. Procedure Steps:
Remove jewelry according to agency policy; push your sleeves above your wrists.
Turn on the water and adjust the flow so that the water is warm. Wet your hands thoroughly, keeping your hands and
forearms lower than your elbows. Avoid splashing water on your uniform.
Apply a palm-sized amount of hand soap.
Perform hand hygiene using plenty of lather and friction for at least 15 seconds:
Rub hands palm to palm
Rub back of right and left hand (fingers interlaced)
Rub palm to palm with fingers interlaced
Perform rotational rubbing of left and right thumbs
Rub your fingertips against the palm of your opposite hand
Rub wrists
Repeat sequence at least two times
Keep fingertips pointing downward throughout
Clean under your fingernails with disposable nail cleaner (if applicable).
Wash for a minimum of 20 seconds.
Keep your hands and forearms lower than your elbows during the entire washing.
Rinse your hands with water, keeping your fingertips pointing down so water runs off your fingertips. Do not shake water
from your hands.
Do not lean against the sink or touch the inside of the sink during the hand-washing process.
Dry your hands thoroughly from your fingers to wrists with a paper towel or air dryer.
Dispose of the paper towel(s).
Use a new paper towel to turn off the water.
Dispose of the paper towel.
View a YouTube video[1] of an instructor demonstrating hand hygiene with soap and water:

Hand Hygiene With Soap and Water

1. Chippewa Valley Technical College. (2022, December 3). Hand Hygiene With Soap and Water. [Video]. YouTube. Video
licensed under CC BY 4.0. https://youtu.be/w29Ad7Cmsxo ↵

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4.9: Skills Checklist- Hand Hygiene With Alcohol-Based Hand Sanitizer
1. Gather Supplies: Antiseptic hand rub
2. Procedure Steps:
Remove jewelry according to agency policy; push your sleeves above your wrists.
Apply enough product into the palm of one hand and enough to cover your hands thoroughly per product directions.
Rub your hands together, covering all surfaces of your hands and fingers with antiseptic until the alcohol is dry (a minimum
of 30 seconds):
Rub hands palm to palm
Rub back of right and left hand (fingers interlaced)
Rub palm to palm with fingers interlaced
Perform rotational rubbing of left and right thumbs
Rub your fingertips against the palm of your opposite hand
Rub your wrists
Repeat hand sanitizing sequence a minimum of two times.
Repeat hand sanitizing sequence until the product is dry.
View a YouTube video[1] of an instructor demonstrating hand hygiene with alcohol-based hand sanitizer:

Hand Hygiene With Alcohol Based Hand…

Hand…

1. Chippewa Valley Technical College. (2022, December 3). Hand Hygiene With Alcohol-Based Hand Sanitizer. [Video].
YouTube. Video licensed under CC BY 4.0. https://youtu.be/rTuO8SYYfNo ↵

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4.10: Skills Checklist- Removing Gloves
1. Procedure Steps:
Using either hand, grasp the glove at the palm of the other hand.
Remove the glove.
Grasp the empty glove within the palm of the gloved hand.
Using the index and middle fingers of the bare hand, slide fingers underneath the remaining glove at the wrist.
Turn the remaining glove inside out while containing the first glove inside.
Discard in an appropriate receptacle.
Perform hand hygiene.
View a YouTube video[1] of an instructor demonstrating removing gloves:

Removing Gloves

[2]
Figure 4.17 Glove Removal

Figure 4.17 Glove Removal

1. Chippewa Valley Technical College. (2022, December 3). Removing Gloves. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/nYDB6b3K-MY ↵
2. “Ch.5-Taking-off-PPE-–-Step-8,” Ch.5-Taking-off-PPE-Step-1a-.png,” “Ch.5-Taking-off-PPE-Step-1c.png,” “Ch.5-Taking-off-PPE-Step-
1d,” “Ch.5-Taking-off-PPE-Step-1e.png,” and “Ch.5-Taking-off-PPE-Step-2.png” by unknown author are licensed under CC BY-NC 4.0.

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 Access for free at https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/putting-it-all-together-putting-on-and-taking-off-full-
ppe/ ↵

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4.11: Skills Checklist- Donning/Doffing PPE Without a Mask
1. Gather Supplies: Gown, gloves, and alcohol-based sanitizer
2. Procedure Steps:
Perform hand hygiene.
Face the back opening of the gown.
Unfold the gown.
Put your arms into the sleeves.
Secure the neck opening behind your head.
Secure the waist, making sure that the back flaps overlap each other and cover your clothing as completely as possible.
Put on gloves.
Ensure the gloves overlap the gown sleeves at the wrist.
When care has been completed and before leaving the room, remove the gloves BEFORE removing the gown.
Remove the gloves, turning them inside out.
Dispose of the gloves in the appropriate container.
Perform hand hygiene.
Unfasten the gown at the neck.
Unfasten the gown at the waist.
Remove the gown starting at the top of the shoulders, turning it inside out and folding soiled area to soiled area.
Dispose of the gown in an appropriate container.
Perform hand hygiene.
View a YouTube video[1] of an instructor demonstrating donning/doffing PPE without a mask:

Donning and Do ng PPE Without a Mask

1. Chippewa Valley Technical College. (2022, December 3). Donning/Doffing PPE Without a Mask. [Video]. YouTube. Video
licensed under CC BY 4.0. https://youtu.be/yP1eIqGJSS8 ↵

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4.12: Skills Checklist- Donning/Doffing PPE With a Mask and Face Shield or
Goggles
1. Gather Supplies: Gown, mask, face shield, goggles, and alcohol-based sanitizer
2. Procedure Steps:
Face the back opening of the gown.
Unfold the gown.
Put your arms into the sleeves.
Secure the neck opening at the back of your neck.
Secure the waist, making sure that the back flaps overlap each other and covering your clothing as completely as possible.
Put on a mask and, if needed, goggles or face shield.
Put on gloves.
Ensure the gloves overlap the gown sleeves at the wrist.
When care is complete and before leaving the room, remove the gloves BEFORE removing the gown.
Remove the gloves, turning them inside out.
Dispose of the gloves in the appropriate container.
Perform hand hygiene.
Remove any goggles or face shield and place in the appropriate receptacle.
Unfasten the gown at the neck.
Unfasten the gown at the waist.
Remove the gown starting at the top of the shoulders, turning it inside out and folding soiled area to soiled area.
Dispose of the gown in an appropriate container.
Remove the mask by grasping loop behind ear or untying at back of head.
Perform hand hygiene.

[1]
Review the Sequence for putting on personal protective equipment PDF handout from the Centers for Disease Control and
Prevention (CDC) with current recommendations for putting on and removing PPE.

View a YouTube video[2] of an instructor demonstrating donning/doffing PPE with a mask and face shield or goggles:

Donning and Do ng PPE with a Mask a…

a…

1. Centers for Disease Control and Prevention. (n.d.). Sequence for putting on personal protective equipment [Handout].
https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf ↵
2. Chippewa Valley Technical College. (2022, December 3). Donning/Doffing PPE With a Mask and Face Shield or Goggles.
[Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/H-rXxFkmWBY ↵

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4.13: Learning Activities

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4.14: IV Glossary
Airborne precautions: Transmission-based precautions used for clients with diagnosed or suspected pathogens spread by very
small airborne particles from nasal and oral secretions that can float long distances through the air, such as measles and
tuberculosis.
Blood-borne pathogens: Infectious microorganisms in blood and body fluids that can cause disease, including hepatitis B (HBV),
hepatitis C (HCV), and human immunodeficiency virus (HIV).
Carrier: An individual who is colonized with an infectious agent.
Chain of infection: The process of how an infection spreads based on six links of transmission: Infectious Agent, Reservoir, Portal
of Exit, Modes of Transmission, Portal of Entry, and Susceptible Host.
Colonization: A condition when a person carries an infectious agent but is not symptomatic or ill.
Contact precautions: Transmission-based precautions used for clients with known or suspected infections transmitted by touch
such as C-difficile (C-diff), methicillin-resistant staphylococcus aureus (MRSA), vancomycin resistant enterococcus (VRE), or
norovirus.
Disinfection: The removal of microorganisms. However, disinfection does not destroy all spores and viruses.
Doff: Take off personal protective equipment (PPE).
Don: Put on personal protective equipment (PPE).
Droplet precautions: Transmission-based precautions used for clients with a diagnosed or suspected pathogen that is spread in
small droplets from sneezing or in oral and nasal secretions, such as influenza or pertussis.
Eye protection: Face shields, visors attached to masks, and goggles that are used to protect the eyes from blood or body fluids.
Fever: A temperature of 38 degrees Celsius (100.4 degrees F).
Hand hygiene: The process of removing, killing, or destroying microorganisms or visible contaminants from the hands. There are
two hand-hygiene techniques: handwashing with soap and water and the use of alcohol-based hand rub (ABHR).
Healthcare-associated infection (HAI): An infection that develops in an individual after admission to a health care facility or
undergoing a medical procedure.
Infection control: Methods to prevent or stop the spread of infections in health care settings.
Infectious agent: Microorganisms, such as bacteria, viruses, fungi, or parasites that can cause infectious disease.
Inflammation: Redness, warmth, swelling, and tenderness associated with early signs of infection.
Isolation gowns: Protective garments worn to protect clothing from the splashing or spraying of body fluids and reduce the
transmission of microorganisms.
Malaise: A feeling of discomfort, illness, or lack of well-being that is often associated with infection.
Masks: Protective coverings worn by health care providers to protect the mucous membranes of their nose and mouth.
Medical asepsis: Techniques used to prevent the transfer of microorganisms from one person or object to another but do not
completely eliminate microorganisms.
Mode of transmission: The way an infectious agent travels to other people and places.
Moments of hand hygiene: Appropriate times during patient care to perform hand hygiene, including immediately before
touching a patient; before performing an aseptic task; before moving from a soiled body site to a clean body site; after touching a
patient or their immediate environment; after contact with blood, body fluids, or contaminated surfaces (with or without glove use);
and immediately after glove removal.
Nonspecific defenses: Generic barriers that prevent pathogens from entering the body, including physical, mechanical, or chemical
barriers.
PAPR: An air-purifying respirator that uses a blower to force air through filter cartridges or canisters into the breathing zone of the
wearer. This process creates an air flow inside either a tight-fitting facepiece or loose-fitting hood or helmet, providing a higher

4.14.1 https://med.libretexts.org/@go/page/70327
level of protection against aerosolized pathogens.
Perineal care: Cleansing the genital and rectal areas of the body.
Personal protective equipment (PPE): Specialized clothing or equipment used to prevent the spread of infection, including
gloves, gowns, facial protection (masks and eye protection), and respirators.
Portal of entry: The route by which an infectious agent enters a new host.
Portal of exit: The route by which an infectious agent escapes or leaves the reservoir.
Purulent drainage: Yellow, green, or brown drainage associated with signs of infection.
Reservoir: The host in which infectious agents live, grow, and multiply.
Respirator masks: Masks with N95 or higher filtration worn by health care professionals to prevent inhalation of infectious small
airborne particles.
Respiratory hygiene: Methods to prevent the spread of respiratory infections, including coughing/sneezing into the inside of one’s
elbow or covering one’s mouth/nose with a tissue when coughing and promptly disposing of used tissues. Hand hygiene should be
immediately performed after contact with one’s respiratory secretions. A coughing person should also wear a surgical mask to
contain secretions.
Specific defenses: Immune system processes like white blood cells attacking particular pathogens.
Standard precautions: Precautions used by health care workers during client care when contact or potential contact with blood or
body fluids may occur based on the principle that all blood, body fluids (except sweat), nonintact skin, and mucous membranes
may contain transmissible infectious agents. These precautions reduce the risk of exposure for the health care worker and protect
patients from potential transmission of infectious organisms.
Sterilization: A process used on equipment and the environment that destroys all pathogens, including spores and viruses.
Sterilization methods include steam, boiling water, dry heat, radiation, and chemicals.
Surgical asepsis: The absence of all microorganisms during any type of invasive procedure; used for equipment used during
invasive procedures, as well as the environment.
Susceptible host: A person at elevated risk of developing an infection when exposed to an infectious agent.
Transmission-based precautions: Specific types of personal protective equipment (PPE) and practices used with clients with
specific types of infectious agents based on the pathogen’s mode of transmission.

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 CHAPTER OVERVIEW

5: Provide for Personal Care Needs of Clients

5.1: Introduction to Provide for Personal Care Needs of Clients
5.2: Activities of Daily Living (ADLs)
5.3: Person-Centered Care
5.4: Pre- and Post-Procedural Steps
5.5: Skin Care
5.6: Types of Baths and Techniques
5.7: Assisting With Nutrition and Fluid Needs
5.8: Assistance With Toileting
5.9: Skills Checklist- Partial Bath
5.10: Skills Checklist- Full Bed Bath
5.11: Skills Checklist- Shower
5.12: Skills Checklist- Tub Bath
5.13: Skills Checklist- Shampoo
5.14: Skills Checklist- Foot Care
5.15: Skills Checklist- Nail Care
5.16: Skills Checklist- Skin Care
5.17: Skills Checklist- Back Rub
5.18: Skills Checklist- Perineal Care (Female)
5.19: Skills Checklist- Perineal Care (Male)
5.20: Skills Checklist- Oral Care
5.21: Skills Checklist- Denture Care
5.22: Skills Checklist- Preparing Clients for Meals and Assisting With Feeding
5.23: Skills Checklist- Choking Maneuver
5.24: Skills Checklist- Catheter Care
5.25: Skills Checklist- Emptying Catheter Drainage Bag
5.26: Skills Checklist- Assisting With a Bedpan
5.27: Skills Checklist- Assisting With a Urinal
5.28: Skills Checklist- Changing Incontinence Brief
5.29: Skills Checklist- Dressing A Client Who Needs Total Assistance
5.30: Skills Checklist- Shaving With an Electric Razor
5.31: Learning Activities
5.32: V Glossary

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1
5.1: Introduction to Provide for Personal Care Needs of Clients
Learning Objectives
Provide for personal grooming and hygiene
Assist with nutrition and fluid needs
Assist client with bowel and bladder elimination
Maintain a urinary catheter
Assist client with bowel and bladder retraining

Providing personal care for clients is the primary responsibility of the nursing assistant. Often referred to as Activities of Daily
Living (ADLs), personal care includes anything that a client needs to maintain hygiene, well-being, self-esteem, and dignity.
ADLs are the foundation of health and wellness and a part of providing holistic care. The manner in which personal care is
provided has a large impact on the quality of life for those unable to care for themselves. A professional nursing assistant provides
these services proficiently while also respecting the preferences of residents.

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5.2: Activities of Daily Living (ADLs)
The main function of a nursing assistant is to provide assistance to clients with activities of daily living. Activities of daily living
[1]
(ADLs) include hygiene, grooming, dressing, fluid and nutritional intake, mobility, and elimination needs. See Figure 5.1 for an
illustration of ADLs. Hygiene refers to keeping the body clean and reducing pathogens by performing tasks such as bathing and
oral care. Grooming also keeps the body clean but refers to maintaining a resident’s appearance through shaving, hair, and nail
care.

Figure 5.1 Activities of Daily Living

Specific ADLs are provided based on the time of day and the needs of the resident. Personal care performed in the morning is
referred to as A.M. care, and personal care performed in the evening is referred to as P.M. care. Full baths or showers may be
provided with either A.M. or P.M. care, depending on resident preferences, but a partial bath should be provided each morning.
A.M. care includes tasks such as the following activities:
Toileting, changing incontinence brief (if used), and providing perineal care
Performing oral and/or denture care (before or after breakfast based on resident’s preference)
Assisting with a partial bath, full bath, or shower depending on the resident’s personal schedule
Changing the client’s hospital gown or assisting with dressing
Assisting with grooming, such as shaving or hair care, and applying makeup, accessories, or jewelry per resident preference
Assisting with eating breakfast
Providing hand hygiene to the resident as needed
Assisting with attending activities, physical therapy (PT), and occupational therapy (OT)
Making the bed and tidying the resident’s room
P.M. care includes tasks such as the following activities:
Toileting
Assisting with lunch and dinner
Assisting with a partial bath, full bath, or shower depending on the resident’s personal schedule
Assisting with oral and denture care before bed
Helping with oral care after meals if resident prefers
Washing face and removing makeup if worn
Changing into gown or pajamas
Providing hand hygiene to resident as needed
Tidying the resident’s room

1. “ADL-1024x534.jpg" by unknown is licensed under CC BY-SA 4.0. Access for free at

https://ecampusontario.pressbooks.pub/healthassessment/chapter/functional-health ↵

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5.3: Person-Centered Care
Person-centered care is a care approach that considers the whole person, not just their physical and medical needs. It also refers to
a person’s autonomy to make decisions about their care, as well as participate in their own care. This approach improves health
outcomes of individuals and their families as care is provided according to the resident’s preferences, choices, and habits held
[1]
before they required assistance to care for themselves.
The term “person” acknowledges a human being has rights, especially in relation to decisions and choices as previously discussed
in Chapter 2. It also recognizes that a person is a human being who is made of several human dimensions. These dimensions
include intellectual, environmental, spiritual, sociocultural, emotional, and physical, all of which operate together to form the whole
[2]
person. In providing person-centered care, health care professionals consider all these elements while meeting health care needs.
A nurse aide can focus on an individual’s personhood by spending time communicating with them and finding out what interests
them, what is important to them, what concerns them, and what causes them to feel unsafe. It also includes asking each person how
they would like to be addressed, as well as avoiding demeaning terms like “honey,” “sweetie,” or “sweetheart.” Promote their
dignity by using age-appropriate words and avoiding words like “diaper,” “bib,” “potty,” or “feeders.” The vital element of person-
centered care is effective communication between the health care provider, the client, and the client’s family members or significant
[3]
others. Effective communication facilitates information sharing and trust.
When a nursing assistant helps clients with their ADLs, person-centered care means learning clients’ personal preferences and
routines. Examples of using the person-centered care approach are knowing the time the resident prefers to wake up and go to bed;
their preference for showers, tubs, or bed baths; their preferred arrangement of their belongings; and their mobility issues. Cares are
individualized based on these preferences. Respecting residents’ dignity and privacy is demonstrated by keeping them covered and
warm when bathing, explaining procedures prior to doing them, and protecting their health information. It also means respecting
personal beliefs, being aware of cultural differences, and offering choices and options when available.
It is important to remember that it is often difficult for clients to feel dependent on others to provide their personal care. Nursing
assistants must demonstrate empathy with clients, especially with those who are experiencing the loss of their independence.
Caregivers should allow residents to do as much as possible for themselves, under appropriate supervision, while providing
assistance as needed. Allow them to make decisions about their care and encourage them to perform as much self-care as possible
to promote their independence, self-esteem, and sense of control over their care. An added physical benefit of encouraging
residents to perform self-care is it maintains their strength and mobility, thereby preventing a decline in physical function for as
long as possible.

1. This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 ↵
2. This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 ↵
3. This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 ↵

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5.4: Pre- and Post-Procedural Steps
Each time a nursing assistant provides personal cares, there are routine steps that should be performed before and after the
interaction, regardless of the skills provided. Having a list of routine steps ensures the following:
Important aspects of care won’t be overlooked.
Dignity for the client and respect for their preferences are provided.
Risk for transmission of pathogens is reduced.
Safety is provided.
Necessary equipment and supplies are present.
Before providing care to a resident, follow the SKWIPE acronym:
Supplies: Many supplies are kept in the resident’s room, but ask yourself if anything is needed that is not available in the room.
Being prepared prevents disruption of the procedure and possible delays that can result in discomfort for the resident.
Knock: Always knock before entering a room, even if the door is open. Knocking maintains dignity for the client and shows
respect for their privacy.
Wash: Always perform hand hygiene when entering the resident’s room to reduce the risk of transmitting pathogens from other
residents, equipment, or environmental surfaces.
Introduce and Identify: Introduce yourself to the resident with your name and your title or position at the facility. Identify the
client following facility policy. For example, properly identifying a client in a hospital setting may include asking them their
name and date or birth and checking their medical ID band. However, in a long-term care setting, some residents may have
cognitive or sensory deficits and may not correctly state their own name, so asking their name is not always a safe manner to
identify them. Instead, identification in long-term care settings is typically performed by using a photograph in the medical
record or by asking another experienced staff member to confirm identification.
Privacy: Provide privacy by closing the door and pulling the privacy curtain to ensure dignity when providing personal care.
Explain: Explain what care you will be providing so the resident can ask questions or decline care if it is not desired at that
time.
After providing care to a resident, but before leaving the room, follow the CLOWD acronym:
Comfort: Ask if the resident is comfortable and if they need anything else such as tissues, water, TV remote, etc.
Light, Lock, and Low: Place the resident’s call light within reach so they can call for staff when they need assistance. Check the
brakes on the bed to ensure they are locked, and the bed won’t move. Place the bed in the lowest position. These and other
measures such as ensuring bed and/or chair alarms are in place and turned on are vital for ensuring patient safety. If a resident
decides to self-transfer out of bed instead of requesting assistance, locking and lowering the bed will reduce the risk of injury
because it is lower to the floor and won’t move suddenly out from underneath them.
Open: Open the door and privacy curtain. For safety reasons, residents must be within staff eyesight when they are alone in
their rooms, unless they are physically able to move independently.
Wash: Perform hand hygiene before leaving the room to reduce the risk of transmitting pathogens to another resident,
equipment, or environmental surfaces.
Document: Ask yourself if you provided any cares that should be documented in the medical record or if you need to report
anything to the nurse or other staff member. Routine cares (i.e., those cares provided to every resident every day) are not
necessarily documented unless they are declined or something out of the ordinary occurred or was observed. Follow agency
policy regarding documentation.

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5.5: Skin Care
[1]
Skin is made up of three layers: epidermis, dermis, and hypodermis. See Figure 5.2 for an illustration of skin layers. The
epidermis is the thin, topmost layer of the skin. It contains sweat gland duct openings and the visible part of hair known as the hair
shaft. Underneath the epidermis lies the dermis where many essential components of skin function are located. The dermis contains
hair follicles (the roots of hair shafts), sebaceous oil glands, blood vessels, endocrine sweat glands, and nerve endings. The
bottommost layer of skin is the hypodermis (also referred to as the subcutaneous layer). It mostly consists of adipose tissue (fat),
[2]
along with some blood vessels and nerve endings. Beneath the hypodermis layer lie bone, muscle, ligaments, and tendons.

Figure 5.2 Layers of the Skin

As discussed in Chapter 4, the skin is the body’s first layer of defense against pathogens entering the body. Maintaining healthy skin
is an integral responsibility of the nursing assistant. Nursing assistants provide the vast majority of bathing and are able to observe
and report any changes to skin integrity while performing ADLs on a daily basis. Impaired skin integrity refers to skin that is
damaged or not healing normally. An example of impaired skin integrity is a pressure injury (also called a bedsore or pressure ulcer)
[3]
with damage to the skin and surrounding tissue. See Figure 5.3 for an image of a pressure injury on a client’s lower back above
their buttocks.

Figure 5.3 Pressure Injury

Age-Related Changes in the Skin

Several changes occur in the skin as one ages. As people age, the amount of adipose tissue decreases. Adipose tissue (i.e., body fat)
[4]
provides insulation to keep one warm, as well as protection against injury by cushioning underlying structures. See Figure 5.4 for
an image of age-related changes in the skin on the hand of an older adult.

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 Figure 5.4 Age-Related Changes in Skin
Oil glands are less productive, making skin drier and more susceptible to cracking. Dry skin and cracked skin make older adults
more susceptible to injuries, like skin tears and pressure injuries, that create openings for pathogens and increase the risk of
infection. NAs can encourage good nutrition and hydration to help maintain good skin integrity.
Older residents also have reduced production of sweat, which affects the ability of their body to regulate their temperature. This
makes them more susceptible to heat-related illness such as exhaustion and heat stroke, especially when being physically active in
[5]
the heat.

Skin Care Needs of Older Adults

Due to less oil and sweat production as one ages, daily showering or full body bathing is not necessary and can even be damaging to
skin. Additionally, residents in long-term care settings don’t typically venture out into the community regularly, thus reducing their
exposure to pathogens. Due to these factors, daily partial baths are provided to maintain hygiene, but full body bathing is typically
performed only weekly.
It is important to adequately dry skin folds and moisturize the skin regularly to maintain skin integrity and prevent dryness,
cracking, and infection. Additionally, clients who are immobile should be repositioned at least every two hours to reduce the risk of
pressure injuries. Repositioning techniques can be found in Chapter 8.

Chronic Conditions Affecting Skin Integrity

Skin needs oxygen and nutrients carried in blood to stay healthy. Any condition that impairs blood flow will increase the risk of
skin conditions. As a person ages, a general decline in cardiac function decreases blood flow and oxygen to the skin, putting all
older adults at increased risk for skin breakdown. Common medical disorders affecting skin health include high cholesterol that
causes blockages of blood flow in the arteries, heart failure, high blood pressure, and diabetes.
Clients with diabetes are prone to developing wounds on their feet that can quickly become infected and require amputation. See
[6]
Figure 5.5 for an image of wounds on the foot of a client with diabetes. Nursing assistants should carefully observe the client’s
feet and in between their toes daily and report any concerns to the nurse to preserve skin integrity. Nail care for diabetics should be
performed by the Registered Nurse (RN) due to the increased risk of infection.

Figure 5.5 Wounds on the Foot of a Client With Diabetes

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Skin care is important for all clients, but additional moisturizing and frequent repositioning should be performed for clients with
increased risk for skin breakdown. See Chapter 8 and 11 for more specific information on risks for skin breakdown and maintaining
skin integrity.

1. “501 Structure of the skin.jpg” by OpenStax is licensed under CC BY 3.0. Access for free at
https://openstax.org/books/anatomy-and-physiology/pages/5-1-layers-of-the-skin ↵
2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
3. “Decubitus 01.jpg” by AfroBrazilian is licensed under CC BY-SA 3.0 ↵
4. “hands-578918_1280.jpg” by Gaertringen on Pixabay.com is licensed under CC0 ↵
5. Balmain, B. N., Sabapathy, S., Louis, M., & Morris, N. R. (2018). Aging and thermoregulatory control: The clinical implications
of exercising under heat stress in older individuals. BioMed Research International, 2018, 8306154.
https://doi.org/10.1155/2018/8306154 ↵
6. “Two_ischaemic_ulcers_on_the_foot_of_an_individual_with_type_2_diabetes.jpg” by Bondegezou is licensed under CC BY-
SA 4.0 ↵

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5.6: Types of Baths and Techniques
There are four basic types of baths that are provided based on the needs, preferences, and mobility of clients: a partial bath, shower,
tub bath, or full bed bath.
A partial bath includes washing the face, underarms, arms, hands, and perineal (genital and anal) area. Partial baths are given
daily to maintain hygiene. They preserve skin integrity by not drying out skin with excessive soap and water use. A shower is
[1]
provided for those who can safely sit in a shower chair or stand with supervision in the shower. See Figure 5.6 for an image of a
shower chair with a transfer bench. A tub bath can be performed in a regular tub or whirlpool. A tub bath may be used for a fully
independent resident or if there is a provider order for a bath treatment such as Epsom salts or oatmeal. A complete bed bath is a
bath provided for clients who have difficulty getting out of bed, are experiencing excessive pain, or have other physical or
cognitive issues that make other types of bathing less tolerable.

Figure 5.6 Shower Chair With Transfer Bench

A resident has the right to choose any type of bath as long as it is safe to do so. A whirlpool bath can be relaxing and enjoyable for
any resident, whereas a bed bath can maintain warmth while keeping the majority of the body covered.
If a resident is hesitant about bathing, different types of baths should be offered based on their preference. It is also possible to
delay a scheduled bath to a different time of day or an alternate day, as long as their hygiene needs are being met. If a resident
continues to be resistant to bathing, different approaches should be attempted until the person is comfortable and hygiene is
maintained. Keep in mind that resistance to bathing can be common during the aging process, especially in clients with dementia as
the disease progresses.

Visit the following site to read additional bathing techniques and products for unique situations: Bath Without a Battle.

Considerations During Bathing

Nursing assistants should maintain privacy and comfort for those receiving assistance with bathing. Residents can become
uncomfortable due to many factors during bathing. For example, if they require transportation to the shower area in the hallway on
a shower chair, the chair can be uncomfortable or cold, or they may be concerned about being exposed. Bath blankets should be
placed over the resident, paying attention to tucking the blanket behind the resident’s back and underneath their legs to keep any
skin from showing. Residents should also wear shoes or socks to prevent any skin injuries to feet. A towel over the top of their
head can assist in keeping them warm, and the shower chair can be padded around the seat with towels or washcloths. Often the
seat back is made of mesh to aid in water drainage, which can be covered with a towel to prevent irritation to the resident’s back
and shoulders. If the resident’s feet don’t reach the support bar of the chair, a wash basin can be turned upside down and placed
under their feet to give them a more secure feeling during transport. There is an increased risk for patient falls during bathing, and
NAs must take appropriate measures to prevent falls due to unsteadiness or wet floors or equipment.
During the bath, the aide should work from head to toe to prevent spreading pathogens from the perineal area to other parts of the
body. Start with the face and neck, then proceed to the front and back of the upper body, then the front and back of the legs, and

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finish with the perineal area. The aide must ensure gloves are changed and hand hygiene is performed immediately after
performing perineal care. See Skills Checklists 5.18 and 5.19 regarding performing perineal care for more information.
Because much of the body’s heat is lost through the head, it may be preferable to wash the resident’s hair last. Provide the resident
with a dry washcloth or towel to cover their face and prevent shampoo from getting in their eyes. Gently tipping the head back will
keep the majority of the water from falling onto their face.
When assisting a client with bathing, there are several things to observe, consider, and report to the nurse:
Report any open or reddened areas; dry, flaky skin; bruises; rashes; or irritation. Check all areas of the skin, especially where
moisture can be trapped, such as underneath breasts, in abdominal and groin folds, in armpits, and between the toes. If a client
has an existing wound or skin breakdown, the nurse should be notified prior to the bath so that an assessment can be completed.
Report any foul odors that remain after bathing.
Report subjective or objective signs of pain. For example, the client may pull away when a painful area on their body is touched
with a washcloth.
Report changes in behavior, such as withdrawal or agitation during bathing.
Report any discharge from any mucous membranes.
See Skills Checklists 5.9-5.13 for performing specific steps for each type of bath and shampooing a client’s hair.

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5.7: Assisting With Nutrition and Fluid Needs
Mealtime should be as enjoyable as possible, especially for those clients requiring assistance. As with any other aspect of providing personal
care, nursing assistants should use empathy. Think about what it would feel like if you had cognitive or sensory deficits and could not ask
for what you want to eat even though it is on the plate in front of you. Recognize how the presentation of the food and the table influence
one’s appetite. Consider with whom you like to share your meal. All these factors should be considered when feeding a resident.
Avoid using feeding techniques that are used with young children, such as making noises, moving utensils like airplanes, etc. Residents
should be offered a clothing protector to avoid soiling their clothes or gown, but to maintain their dignity, these protectors should never be
referred to as a “bib.”
When the meal is ready to consume, describe to the resident what they have on their tray to eat and drink. If the client is visually impaired,
use the clock method to describe their plate so they know where each food is located. For example, the nursing assistant can state, “Your
mashed potatoes are at 10 o’clock, the green beans are at 2 o’clock, and the meat loaf is at 6 o’clock on your plate.” If a resident has an order
for a pureed diet (i.e., all food is blended to smooth consistency), know what each food is and name it when assisting the resident.
Nutritional requirements for each resident are determined by the dietary staff. Each resident has a specific type of diet ordered, including
texture and consistency of liquids. It is imperative for nursing assistants to check the resident’s care plan to know what type of diet is
currently ordered and be familiar with the appearance of these types of diets. These steps ensure the correct foods and fluids are provided to
residents and reduces the risk of choking and aspiration. Aspiration refers to inadvertently breathing fluid or food into the airway instead of
swallowing it. Diets are further discussed in Chapter 6. See the “Preparing Clients for Meals and Assisting With Feeding” checklist for
specific steps when assisting clients with feeding.
Things to observe for and report during feeding include the following:
Coughing or frequent clearing of the throat while eating. This may be a sign of aspiration.
A wet voice, meaning vocalization with sounds as if food or fluids remain in the mouth or throat.
Difficulty swallowing.
Pain with chewing or swallowing.
Broken or cracked teeth or dentures that don’t fit properly.
Changes in appetite.
Thinking back to Maslow’s Hierarchy, physiological needs such as food and fluids are the basis of a healthy existence. Digestive,
circulatory, and urinary system changes related to aging will be discussed further in Chapter 11, but aging can pose several risk factors to
nutritional and fluid intake. Poor dentition can cause changes in food choices. Someone with missing, cracked, or painful teeth, ill-fitting
dentures, or other oral concerns may choose softer foods. A declining sense of smell, taste, or vision can decrease appetite. Pain with
movement or other factors that limit mobility may make elimination difficult, which may be a factor in decreasing intake, so toileting needs
are less frequent. These are just a few of the aging issues that can lead to malnutrition, dehydration, or both in aging clients and those unable
to care for themselves.

Feeding Aids
There are several assistive devices that allow residents to more easily feed themselves.
Built-up handles allow the use of utensils by individuals with limited functional ability of their fingers to hold a smaller handle (such as for
someone with severe arthritis). Silverware with prebuilt handles can be purchased, or a foam tube can be placed around regular silverware
and removed for washing.
Weighted silverware has a weighted handle for individuals with tremors or unsteady hands. The weight slows down the shaking and allows
[1]
food to remain on the utensil. See Figure 5.7 for an image of built-up handles and weighted silverware.

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 Figure 5.7 Built-Up and Weighted Silverware
Swivel spoons rotate so if the resident’s hand shakes, the spoon doesn’t move, and the food remains on the utensil. See an image of a swivel
[2]
spoon in Figure 5.8.

Figure 5.8 Swivel Spoon

Covered cups prevent liquids from spilling due to tremors and also slow down the rate of fluid leaving the cup. For example, individuals
with aspiration risk (as discussed in Chapter 6.2, “Nutrition and Fluid Needs”) may be permitted to drink regular liquids out of a covered
[3]
cup rather than requiring thickened liquids. See an image of a covered cup in Figure 5.9.

Figure 5.9 Covered Cup

Nosey cups are used for clients with limited neck mobility. The nosey cup allows them to drink all of the fluid in the cup without tipping
their head back. The cut-out portion of the cup fits around the person’s nose so it can be tilted up to finish the fluid. See an image of a nosey
[4]
cup in Figure 5.10.

Figure 5.10 Nosey Cup

Plate guards are used for individuals who can use only one hand or who have difficulty maneuvering utensils. Food can be pushed onto the
[5]
utensil by pushing it against the plate guard. The plate guard can be placed on any plate (such as the image of the plate in Figure 5.11 ), or it
[6]

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 [6]
may be on a special plate made with the guard built on the plate surface (as in Figure 5.12 ).

Figure 5.11 Plate Guard

Figure 5.12 Built-Up Plate

Documentation of Food and Fluids

Documentation of food and fluids gives insight to the overall health and well-being of clients. It gives nurses, dieticians, health care
providers, and other staff insight into possible health concerns. Documenting intake is an important responsibility of nurse aides. Unless
otherwise indicated, food intake is documented by estimating to the nearest 25% of intake. It is also appropriate to note that a resident only
[7]
ate “bites of food.” See Figures 5.13 – 5.16 for examples of food intake.

Figure 5.13 25% intake or “bites”

Figure 5.14 50% intake

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 Figure 5.15 75% intake

Figure 5.16 100% intake

Any fluids documented in health care are converted to milliliters (mL) or cubic centimeters (cc). Milliliters and cubic centimeters are the
same units, so 1 mL = 1 cc. Typically, fluids are measured in ounces in the United States, so a conversion is necessary. To do so, multiple the
number of ounces by 30, as 1 ounce = 30 cc = 30 mL. Examples of fluid conversions are provided in Table 5.7.
Table 5.7 Conversions of Ounces to Milliliters (mL) or Cubic Centimeters (cc)

Fluid Ounces Conversion Milliliters or Cubic Centimeters

6 oz x 30 180 mL or cc

4 oz x 30 120 mL or cc

1 cup = 8 oz x 30 240 mL or cc

In addition to beverages, anything that melts at room or body temperature is documented as fluids. This includes food items such as clear
broth, ice chips, ice cream, popsicles, and Jell-O. However, soup is documented as part of the client’s food intake.

1. “Bui -1">↵
2. “Swivel-Spoon-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
3. “Kennedy-Cup-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
4. “Nosey-Cup-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
5. “Plate-Guard-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
6. “Bui -6">↵
7. “25 percent intake.png,” “50 percent intake.png,” “75 percent intake.png,” and “100 percent intake.png” by Nic Ashman for Chippewa
Valley Technical College are licensed under CC BY 4.0 ↵

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5.8: Assistance With Toileting
Just as there are several bathing techniques based on a resident’s functioning and mobility, there are multiple methods for assisting
residents with their bladder and bowel elimination. Regardless of the method used, residents should be offered toileting assistance
at least every two hours. The following subsections provide an overview of each toileting method and when it may be
implemented.

Toilet
The resident should be able to stand independently, walk, or pivot transfer with assistance. A mechanical lift that assists with
bearing weight may also be used to place a resident on the toilet.

Bedpan
Bedpans are used for residents who cannot bear weight or prefer to stay in bed, such as when having to urinate during the night.
Residents who require a full body lift to transfer typically require the use of a bedpan, but there are also toileting slings to assist a
[1]
fully dependent resident to use a toilet or commode. See Figure 5.17 for an image of two types of bedpans. The image on the left
is a standard bedpan and the image on the right is called a fracture pan. Fracture bedpans are smaller than standard bedpans and
have one flat end. They are designed for individuals recovering from a hip fracture or hip replacement.

Figure 5.17 Bedpan Examples

For residents with strong hip mobility who require a bedpan, ask them to bend their knees and push their hips upwards. While they
are raised, place a barrier (e.g., a towel, waterproof soaker pad, disposable pad, etc.) under them and then place a standard bedpan
underneath their buttocks. Ensure the handle of the fracture pan (or the opening of the rim on a full bedpan) is pointed towards the
foot of the bed before they lower themselves onto the bedpan. For residents with limited hip mobility, use their lift sheet to roll
them away from you towards a raised side rail. While they are lying on their side and holding the side rail, return the lift sheet on
top of the bed and then place a barrier on top of the lift sheet. Place a fracture pan behind the resident’s buttocks and then gently
roll both the resident and the fracture pan back to the bed surface, ensuring proper placement of the pan.
Please see Skills Checklist for additional information.

Commode
[2]
A commode looks like a toilet, but it is a movable device with a bucket underneath the seat. See Figure 5.18 for an image of a
commode. Commodes are typically placed near the bed for residents who have limited weight-bearing ability, do not want to share
a bathroom with another resident, or have urge incontinence. Urge incontinence means that as soon as the person feels the need to
empty their bladder, they have very little time before urine escapes.

Figure 5.18 Bedside Commode

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Incontinence Briefs or Pads
Incontinence briefs or pads are disposable products used for residents who have little to no control over bladder or bowel
function and are worn in, or in place of, their underwear. Please see Skills Checklist for additional information.

Urinary Catheter
A urinary catheter is a device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a
collection bag. Urinary catheters are used sparingly due to increased risk of urinary tract infections. Catheters are typically used for
clients with urinary retention, have a wound near the perineal area that may become infected due to incontinence, or have a
[3]
neurological condition that does not allow them to control their bladder function. See Figure 5.19 for an illustration of an
indwelling urinary catheter attached to a collection bag. Nursing assistants may assist in emptying/documenting urine output from
the collection bag or providing catheter care according to agency policy. Please see 5.25 Skills Checklist for additional information.

Figure 5.19 Indwelling Urinary Catheter With a Collection Bag

Urostomy
A urostomy is placed surgically to collect urine from the ureters when the bladder is diseased or has been removed. Urostomies are
[4]
typically located on the lower right side of the abdomen, and urine is collected into a drainage bag. See Figure 5.20 for an
illustration of a urostomy.

Figure 5.20 Urostomy

Colostomy
A colostomy is placed surgically when colon function is impaired. A piece of the colon is diverted to an artificial opening in the
abdominal wall called a stoma, and feces is collected in a pouch.

Considerations When Assisting Clients With Toileting

Nursing assistants must consider a resident’s privacy and dignity when assisting with toileting just as they do with bathing. Most
residents prefer to be alone when urinating or defecating. Privacy can be provided by closing the bathroom door if the resident is

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able to be left alone. If the resident is not safe to be left alone, close the door as much as possible while keeping the resident within
eyesight. Maintain awareness of a resident who is toileting or on the bedpan so they do not need to wait for assistance with perineal
care after elimination and will not develop any skin issues from sitting on a hard surface.
To maintain dignity, nurse aides should be careful when explaining and providing care related to toileting. For example, a
disposable brief should never be referred to as a diaper; acceptable terms include a brief, pad, liner, or disposable underwear.
Additionally, a nurse aide should never show reluctance or appear burdened when providing toileting assistance, no matter how
often a resident feels the need to be toileted or requires perineal care due to incontinence.

Bladder and Bowel Retraining

Clients who are dependent on others for assistance with elimination should be taken to the bathroom or offered toileting options
every two hours. Incontinence is a very personal matter and can be embarrassing for clients. Nursing assistants should use
therapeutic communication when assisting clients with toileting.
When indicated, clients may undergo bladder and bowel retraining to regain control of elimination. There are several strategies
used to promote bladder continence. The nurse aide may assist the nurse with one of the strategies called timed voiding. Timed
voiding encourages the patient to urinate on a set schedule, such as every hour, whether they feel the urge to urinate or not. The
time between bathroom trips is gradually extended with the general goal of achieving four hours between voiding. Timed voiding
helps to control urge and overflow incontinence as the brain is trained to be less sensitive to the sensation of the bladder walls
[5]
expanding as they fill.
Bowel retraining involves teaching the body to have a bowel movement at a certain time of the day. This training includes
encouraging clients to go to the bathroom when feeling the urge to do so and not ignoring the urge. For some individuals, it is
helpful to schedule this consistent time in the morning when the natural urge occurs after drinking warm fluids or eating breakfast.
For other people, especially those with a neurological cause, a laxative may be scheduled regularly to stimulate the urge to have a
bowel movement on a regular basis and prevent constipation. The nurse should communicate to the nursing assistant when bowel
[6]
retraining is in place, or a laxative is administered to a client so they are aware of the client’s need to defecate.
[7]
Urinary Tract Infection (UTI)
A urinary tract infection (UTI) is a common infection that occurs when bacteria, typically from the rectum, enter the urethra and
infect the bladder or kidneys. Infections can affect several parts of the urinary tract, but the most common type is a bladder
infection. Kidney infections are more serious than a bladder infection because they can have long-lasting effects on the kidneys.
Some people are at higher risk of getting a UTI. UTIs are more common in females because their urethras are shorter and closer to
the rectum, which makes it easier for bacteria to enter the urinary tract. Providing improper perineal care is a common cause of a
UTI. Nursing assistants must be diligent and assist with perineal hygiene as needed to prevent infections. Other factors that can
increase the risk of UTIs include the following:
A previous UTI
Sexual activity, especially with a new sexual partner
Pregnancy
Age (Older adults and young children are at higher risk)
Urinary retention
Low fluid intake
Structural problems in the urinary tract, such as prostate enlargement
Symptoms of a UTI should be reported to the nurse immediately and include the following:
Pain or burning while urinating (dysuria)
Frequent urination (frequency)
Urgency with small amounts of urine
Bloody urine
Pressure or cramping in the groin or lower abdomen
Confusion or altered mental status in older adults
Symptoms of a more serious kidney infection (called pyelonephritis) include fever above 101 degrees F (38.3 degrees C), shaking
chills, lower back pain or flank pain (i.e., on the sides of the back), and nausea or vomiting.

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It is important to remember that older adults with a UTI may not exhibit these common symptoms but instead demonstrate an
increased level of confusion. Older adults often become weaker when they have a UTI and may fall. If you notice increased
weakness or a change in the level of confusion in an older client, report these symptoms to the nurse immediately. If not treated
quickly, UTIs can spread to the blood (called septicemia), leading to life-threatening infection called sepsis.
When a patient has symptoms related to a possible UTI, the health care provider will order diagnostic tests, such as a urine dip,
urinalysis, or urine culture. See the subsection below on “Specimen Collection,” which details how nursing aides assist with these
tests. Antibiotics are prescribed for urinary tract infections and are administered by the nurse. Nursing assistants should encourage
clients with UTIs to drink extra fluids to help flush bacteria from the urinary tract, and toileting should be offered more frequently
with proper perineal care.

Observation and Documentation of Urinary Output

When assisting residents with urinary elimination, their urine should be observed for the characteristics described in Table 5.8.
Terms used to document these characteristics are included.
Characteristics of urine can be indicative of a urinary tract infection or dehydration and should be reported to the nurse. Dark urine,
minimal urine output, or the infrequent need to void can be signs of dehydration. Characteristics of an infection are described in the
previous “Urinary Tract Infection (UTI)” subsection. If noted and reported promptly, fluids can be encouraged to help treat these
conditions.
Table 5.8 Urine Characteristics

Characteristic Normal Observation Abnormal Observation Documentation Terminology

Amber (like a stoplight) or straw- Dark amber or possibly root beer

Color Amber or cola
colored or cola-colored

Noticeably stronger odor than

Odor Acidic Strong
usual

Clarity Clear Cloudy Cloudy

Sediment None present Particles present Sediment noted

Amount in milliliters or cubic

Amount Generally 250-350 cc More or less than usual amount centimeters. Minimal amount may
be described as scant

If a resident is regularly incontinent and uses a brief or disposable pad for elimination, the nursing assistant should document the
number of times the resident is incontinent rather than recording the amount. For a continent resident, use a toilet hat to measure
urine output as described in the “Specimen Collection” subsection below. If the resident uses a commode or bedpan, place a
graduated cylinder on a barrier, carefully pour the urine into the graduated cylinder, and observe and document the characteristics.
[8]
See Figure 5.21 for an image of a graduated cylinder.

Figure 5.21 Graduated Cylinder

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Observation and Documentation of Stool
Similar to urine, stool output and characteristics can indicate underlying health concerns. Risk factors to healthy stool elimination
will be discussed further in the “Digestive System” section in Chapter 11, but slowing of the digestive system, decreased intake,
and lower mobility can all contribute to constipation and even cause bowel obstruction. Documentation and reporting of unusual
characteristics can assist nurses in providing interventions that can prevent more serious health concerns.
Elimination patterns vary for each individual, but a typical range for bowel elimination is twice daily to once every other day.
When regular bowel movements do not occur, stool becomes hardened in the colon, making it difficult to push out, especially for
those who are physically declined. Stool should be soft and formed when eliminated to prevent additional problems like
hemorrhoids. Stool that is loose or liquid may indicate an infection or other chronic intestinal issues.
Nursing assistants should note the size of a client’s bowel movement as “small,” “medium,” or “large” as an estimation. Using
agency protocol, the consistency of the stool should also be documented. The Bristol Stool Chart is a common tool used to easily
[9]
observe and document the consistency of stool. See Figure 5.22 for an image of the Bristol Stool Chart. Additionally, if any blood
or dark tarry stool is observed, this should be reported immediately to the nurse.

Figure 5.22 Bristol Stool Chart

[10]
Specimen Collection
Urinary Samples
Urinary samples may need to be collected to detect infection. When needed, obtain a toilet hat (see Figure 5.23“Toilet Hat” and
“Commode with Toilet Hat” by Landon Cerny are licensed under CC BY 4.0[/footnote]
. Ask the nurse to label a specimen cup before collecting urine
[11]
(see Figure 5.24 ).
When assisting in collecting a urine specimen, place the cup and toilet hat on a barrier to prevent contamination with bacteria from
the environment. Apply gloves and assist the client when needed to clean around the urethra to remove any external pathogens. If
able, ask the resident to void a small amount of urine into the toilet. Place the toilet hat in the front of the toilet and instruct the
resident to void into the hat. Do not put toilet paper or any other products into the toilet hat. After urination, assist the resident in
completing perineal care and transferring from the toilet. Remove dirty gloves, perform hand hygiene, and apply new gloves to
prevent contamination of the urine with bacteria from the perineal area. Pour the urine sample from the toilet hat into the specimen
cup and tightly put on its cover. Remove gloves and perform hand hygiene before writing the time of collection on the label.
Immediately bring the urine sample to the nurse.

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 Figure 5.23 Toilet Hat

Figure 5.24 Specimen Cup

Stool Samples
Stool samples are collected from patients to test for cancer, parasites, or for occult blood (i.e., hidden blood). The Guaiac-Based
Fecal Occult Blood Test (gFOBT) is a commonly used test to find hidden blood in the stool that is not visibly apparent. As a
screening test for colon cancer, it is typically obtained by the patient in their home using samples from three different bowel
movements. Nursing assistants may collect gFOBT specimens for clients.
Before the test, the nurse should verify that the client has avoided red meat for three days and has not taken aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDs), such as ibuprofen, for seven days prior to the test. (Blood from the meat can cause a false
positive test, and aspirin and NSAIDS can cause bleeding, also leading to a false positive result.) Vitamin C (more than 250 mg a
day) from supplements, citrus fruits, or citrus juices should be avoided for 3 to 7 days before testing because it can affect the
chemicals in the test and make the result negative, even if blood is present.
To perform a gFOBT in an inpatient setting, perform the following steps.
Verify with the nurse that the client has met dietary and medication requirements.
Explain the procedure to the client. Assist the resident to a clean, dry commode and instruct them not to put any toilet paper in
the commode, as this may alter the test result. Request they use the call light when they have had a bowel movement.
Review the manufacturer’s instructions with the nurse.
Label the card with the patient’s name and medical information per agency policy. Open the flap of the guaiac test card.
Apply nonsterile gloves. Use the applicator stick to apply a thin smear of the stool specimen to one of the squares of filter paper
on the card. Obtain a second specimen from a different part of the stool and apply it to the second square of filter paper on the
card. (Occult blood isn’t typically equally dispersed throughout the stool.)
Place the labeled test card in a transport bag.
Remove gloves and perform hand hygiene.
Give the transport bag to the nurse to send to the laboratory for analysis.

1. “Bedpan.jpg”, "Fracture Bedpan.jpg", and "Fracture Bedpan View 2.jpg" by Landon Cerny are licensed under CC BY 4.0 ↵
2. “Bedside Commode” by Landon Cerny is licensed under CC BY 4.0 ↵
3. "Foley Catheter with Collection Bag and Leg Strap" by Landon Cerny is licensed under CC BY 4.0 ↵
4. “Diagram_showing_how_a_urostomy_is_made_(ileal_conduit)_CRUK_124.svg” by Cancer Research UK is licensed under CC
BY-SA 4.0 ↵
5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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 7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
8. "Graduated Cylinder" by Landon Cerny is licensed under CC BY 4.0 ↵
9. “Bristol_stool_chart.svg” by Cabot Health, Bristol Stool Chart is licensed under CC BY-SA 3.0 ↵
10. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
11. “Sterile Specimen Container" by Landon Cerny are licensed under CC BY 4.0 ↵

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5.9: Skills Checklist- Partial Bath
1. Gather Supplies: Wash basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, clean clothes or gown, and
[1]
linen bag or hamper. See Figure 5.25 at the end of this checklist for an image of a wash basin.
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Put on gloves.
Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water
temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
Raise the bed height to a working height.
Keep the resident covered as much as possible using a bath blanket or bed linens.
Wash the resident’s face using water only.
Pat dry the face.
Remove the gown from one arm, keeping the rest of the body covered.
Place a towel under one arm, only exposing the arm.
Wet a washcloth, put soap on the washcloth, and wash the arm with soap.
Wash the hand with soap.
Wash the underarm with soap. Place the washcloth containing soap on the edge of the basin or barrier.
Rinse the arm with the second washcloth.
Rinse the hand.
Rinse the underarm.
Pat dry the arm.
Pat dry the hand.
Pat dry the underarm.
Move to the other side of the bed and repeat actions on the other side of the body.
Dispose of the gown into a linen bag or laundry hamper.
Ask the resident if they would like lotion. When applying lotion, wear gloves.
Assist the resident to put on a clean gown or clothes.
While wearing gloves, empty the equipment.
Rinse the equipment.
Dry the basin.
Return the equipment to storage.
Dispose of soiled linen in the designated laundry hamper.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and if anything else is needed.
Be sure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.

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 Figure 5.25 Wash Basin
View a YouTube video[2] of an instructor demonstrating a partial bath:

Partial Bath

1. "Wash Basin" by Landon Cerny is licensed under CC BY 4.0 ↵

2. Chippewa Valley Technical College. (2022, December 3). Partial Bath. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/iR1r-_SKVpc ↵

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5.10: Skills Checklist- Full Bed Bath
1. Gather Supplies: Basin, warm water, soap, shampoo and conditioner if used, lotion, six washcloths, two towels, barrier, gloves,
clean clothes or gown, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water
temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
Place a towel under one leg, keeping the rest of the body covered with the bath blanket.
Wash the leg with soap, only exposing the leg.
Wash the feet with soap.
Rinse the leg and feet.
Pat the leg and feet dry.
Repeat on the other leg.
Raise the side rail on one side of the bed.
Move to the opposite side of the bed and assist the resident to roll on their side using a lift sheet or other supportive device.
Wash the back while keeping the rest of the body covered.
Rinse the back.
Pat the back dry.
Dispose of the gown and used linens into the linen bag or laundry hamper.
Ask the resident if they would like lotion. If applying lotion, wear gloves.
Perform perineal care using clean linens according to Chapters 5.18 & 5.19 “Perineal Care Skills Checklists.”
Assist the resident to put on a clean gown or clothes and apply an incontinence product if needed.
While wearing gloves, empty the equipment.
Rinse the equipment.
Dry the basin.
Return the equipment to storage.
Dispose of soiled linen in the designated laundry hamper.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and if anything else is needed.
Be sure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.
Note: Shampooing can be done before washing face, after washing back, or after perineal care per resident preference. See
“Shampoo Skills Checklist” for specific steps.
View a YouTube video[1] of an instructor demonstrating a full bed bath:

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 Full Bed Bath

1. Chippewa Valley Technical College. (2022, December 3). Full Bed Bath . [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/j5GYMOvjjtk ↵

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5.11: Skills Checklist- Shower
1. Gather Supplies: Soap, shampoo and conditioner if used, lotion, two washcloths, several towels, barrier, gloves, clean clothes or
gown, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Assist the resident to the shower per facility protocol. See the “Considerations During Bathing” subsection in this chapter
and implement comfort measures. Keep the resident covered as long as possible and have the resident test the water
temperature on their fingers. Repeatedly check the water temperature throughout the shower.
Put on gloves.
Wet a washcloth and wash the face without soap.
Put soap on the washcloth and wash the resident, starting with their upper body and then their legs.
Lift any skin-on-skin areas and wash gently with soap.
Wash the front of the perineal area.
Reach through the bottom of the shower chair and wash the rectal area from front to back.
Remove the gloves, turning them inside out.
Perform hand hygiene.
Put on clean gloves.
Rinse the resident starting with the upper body, followed by the legs, front perineal area, and rectal area.
Change the gloves and perform hand hygiene if the perineal area was touched during rinsing.
Turn off the water and place warm towels to cover the resident
Pat dry.
Ask the resident if they would like lotion. If applying lotion, wear gloves.
Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair and avoiding
getting the gown or clothes wet.
Place nonskid footwear on the client.
Assist the resident to stand per their care plan.
Dry the back of their legs
Dry the perineal area from front to back
Finish putting on clothes.
Assist the resident to a wheelchair or other preferred surface, changing gloves and performing hand hygiene as soon as the
resident is safely seated.
Place all linens and soiled gown or clothing in a linen bag or designated hamper.
Sanitize the shower chair per facility policy.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Be sure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.

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5.12: Skills Checklist- Tub Bath
1. Gather Supplies: Soap, shampoo and conditioner if used, lotion, four washcloths, four towels, barrier, gloves, clean clothes or
gown, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Keep the resident covered as long as possible and have the resident test the water temperature on their fingers. Assist the
resident to the tub per facility protocol. See the subsection in this chapter called “Considerations During Bathing” for
comfort measures. Repeatedly check the water temperature throughout the bath.
Put on gloves.
Wash the client’s face with a washcloth and no soap.
Put soap on the washcloth and wash the resident starting with their upper body and then their legs.
Lift any skin-on-skin areas and wash gently with soap.
Perineal care can be performed in the bed prior to the bath. See Skills Checklists 5.18 and 5.19 for perineal care specifics.
Wash the client’s hair. See the “Shampoo” checklist for specific steps.
Drain the tub per facility protocol and rinse the resident.
Place warm towels to cover the resident.
Pat dry.
Ask the resident if they would like lotion. If applying lotion, wear gloves.
Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair to prevent
getting the gown or clothes wet.
Place nonskid footwear on the client.
Assist the resident to stand per their care plan.
Dry the back of their legs.
Dry the perineal area from front to back.
Finish putting on clothes.
Assist the resident to a wheelchair or other preferred surface, changing gloves and performing hand hygiene as soon as the
resident is safely seated.
Place all linens and soiled gown or clothing in a linen bag or designated hamper.
Sanitize the bath chair per facility policy.
Remove the gloves by turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Be sure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.

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5.13: Skills Checklist- Shampoo
1. Gather Supplies: Shampoo basin if in bed, shampoo, conditioner if used, two washcloths or small towels, one large towel,
gloves, and linen bag
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Place a basin underneath the client’s head and neck if they are in bed and place the drain over the garbage can located on the
floor.
Give the client a dry washcloth or towel to cover their face if desired.
Check the water temperature for safety and comfort. Have the resident check the water temperature by placing their hand in
the water in the basin or putting a wet washcloth on the back of their hand. Ask the resident if the temperature is
comfortable to them.
Wet their hair with a wet washcloth or by gently pouring water over their hair.
Apply shampoo and lather while massaging scalp gently.
Rinse their hair.
Apply conditioner if used, massaging the scalp gently.
Rinse their hair.
Dry their hair gently and style it per the resident’s preference.
While wearing gloves, empty the equipment.
Rinse the equipment.
Dry the basin.
Return the equipment to storage.
Dispose of soiled linen in a designated laundry hamper.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin or scalp issues or changes noted with the resident.

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5.14: Skills Checklist- Foot Care
1. Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Fill a foot basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water
temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
Remove their socks.
Immerse their feet in warm water for 5 to 20 minutes.
Use water and a soapy washcloth.
Wash each foot and between the toes.
Rinse the entire foot with the wet washcloth, including between the toes.
Dry the foot thoroughly, including between the toes.
Ask the resident if they would like lotion. If applying lotion, wear gloves.
Massage the lotion over the foot but avoid applying any lotion between the toes.
Wipe off any excess lotion with a dry towel.
Replace the socks or preferred footwear.
While wearing gloves, empty the equipment.
Rinse the equipment.
Dry the basin.
Return the equipment to storage.
Dispose of soiled linen in a designated laundry hamper.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin or nail issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating foot care:

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 Foot Care

1. Chippewa Valley Technical College. (2022, December 3). Foot Care. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/gQekzAPHKGY ↵

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5.15: Skills Checklist- Nail Care
NOTE: Nail care for clients with diabetes should be performed by a Registered Nurse (RN).
1. Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, manicure stick, emery board, nail
clipper, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water
temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
Have the resident perform hand hygiene with sanitizer.
Immerse the client’s hands in warm water for 5 to 20 minutes.
Place their hand on a barrier.
Using a manicure stick, clean underneath each nail, wiping any debris on the barrier after each nail.
If necessary, trim nails using a clipper. Sanitize the clipper prior to and after use.
Using an emery board, file each nail from the outside of the nail towards the middle of the nail.
Check each nail for snags and file until smooth.
Rinse the hand in water, return to the barrier, and dry.
Repeat the procedure for the second hand.
Offer lotion. If applying lotion, wear gloves.
Rub the lotion gently into the skin if requested.
Wipe off any excess lotion with a dry towel.
While wearing gloves, empty the equipment.
Rinse the equipment.
Dry the basin.
Return the equipment to storage.
Dispose of soiled linen in a designated laundry hamper.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene
Document and report any skin or nail issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating nail care:

5.15.1 https://med.libretexts.org/@go/page/70343
 Nail Care

1. Chippewa Valley Technical College. (2022, December 3). Nail Care. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/T32Csl2Rx0s ↵

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Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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5.16: Skills Checklist- Skin Care
1. Gather Supplies: Gloves and lotion
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene and put on gloves.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Position the resident as needed and only expose the skin that will be moisturized.
Put on gloves.
Place a quarter-sized circle of lotion on one palm.
Rub the hands together to warm the lotion.
Apply the lotion to dry skin but avoid getting lotion between the toes.
Use additional lotion, warming between your hands as needed, until all dry skin has been moisturized.
Wipe off any excess lotion gently with a dry towel.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.
It is important to properly clean the wash basin and other supplies after performing any type of skin care to prevent the spread of
infection.
View a YouTube video[1] of an instructor demonstrating cleaning supplies after performing skin care:

Cleaning Supplies After Performing Skin…

Skin…

1. Chippewa Valley Technical College. (2022, December 3). Post Skin Care Procedure. [Video]. YouTube. Video licensed under
CC BY 4.0. https://youtu.be/yZ_VfxFxUho ↵

This page titled 5.16: Skills Checklist- Skin Care is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra
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request.

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5.17: Skills Checklist- Back Rub
1. Gather Supplies: Gloves and lotion
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Raise the side rail on one side of the bed.
Move to the opposite side of the bed and assist the resident to roll towards the raised side rail.
Only expose the resident’s back from the shoulders to the top of the hips.
Place a quarter-sized circle of lotion on one palm.
Rub the hands together to warm the lotion.
Begin with long, gentle strokes starting at the top of hips and moving to the top of the shoulders. Repeat about five times.
Throughout the back rub, ask the resident if there is any pain or discomfort. If pain is present, stop the procedure and report
it to the nurse.
Apply more lotion to gloved hands as needed to reduce friction on the resident’s skin.
Make large circles with both hands from the top of hips to the top of shoulders. Repeat about five times.
Apply additional lotion to gloved hands as needed to reduce friction on resident’s skin.
Make small circles with both hands from the top of the hips to the top of the shoulders. Repeat about five times.
Apply additional lotion to gloved hands if needed to reduce friction on resident skin.
End with long, gentle strokes starting at the top of hips and moving to the top of shoulders. Repeat about five times.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Cover the resident completely per resident preference.
Assist the resident to their preferred position.
Lower the side rail that was raised.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating a backrub:

5.17.1 https://med.libretexts.org/@go/page/70345
 Back Rub

1. Chippewa Valley Technical College. (2022, December 3). Back Rub. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/CqFgIrLaQ4M ↵

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Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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5.18: Skills Checklist- Perineal Care (Female)
1. Gather Supplies: Basin, warm water, soap, four washcloths, one towel, barrier, gloves, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Raise one side rail of the bed after checking the resident’s mobility and their preferred side to lie on.
Put on gloves.
Raise the bed height if needed.
Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water
temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
Turn the resident or raise their hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their
buttocks.
Expose their perineum only.
Separate the labia.
Use water and a soapy washcloth.
Clean one side of the labia from top to bottom.
Using a clean portion of the first washcloth, clean the other side of the labia from top to bottom.
Using a clean portion of the first washcloth, clean the vaginal area from top to bottom.
Put the first washcloth in the linen bag.
Using the second clean washcloth, rinse one side of the labia from top to bottom.
Using a clean portion of the second washcloth, rinse the other side of the labia from top to bottom.
Using a clean portion of the second washcloth, rinse the vaginal area from top to bottom.
Put the second washcloth in the linen bag.
Avoid overexposure throughout the procedure.
Pat dry.
Cover the exposed area with the bath blanket.
Assist the resident to turn onto their side facing away from you and ask the resident to hold onto the raised side rail.
Using the third clean washcloth, apply water and soap.
Using a clean portion of the third washcloth, clean one side of the buttock, wiping away from vagina.
Using a clean portion of the third washcloth, clean the other side of the buttock, wiping away from the vagina.
Using a clean portion of the third washcloth, clean the rectal area wiping away from the vagina.
Put the third washcloth in the linen bag.
Using the fourth washcloth, rinse one side of the buttock wiping away from the vagina.
Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the vagina.
Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from vagina.
Put the fourth washcloth in the linen bag.
Pat dry.
Safely remove the waterproof pad from under the buttocks.
Remove the gloves, turning them inside out.
Perform hand hygiene.
Position the resident on her back.
Put on clean gloves.
Dispose of soiled linen in the designated laundry hamper.
Empty the equipment.
Rinse the equipment.
Dry the equipment.

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 Return the equipment to storage.
Remove the gloves, turning them inside out.
Dispose of the gloves in an appropriate container.
4. Post- Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.
[1]
View a YouTube video of an instructor demonstrating female perineal care:

Perineal Care - Female

1. Chippewa Valley Technical College. (2022, December 3). Perineal Care (Female). [Video]. YouTube. Video licensed underCC
BY 4.0. https://youtu.be/6Xu2Sgk1y80 ↵

This page titled 5.18: Skills Checklist- Perineal Care (Female) is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by
Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available
upon request.

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5.19: Skills Checklist- Perineal Care (Male)
1. Gather Supplies: Basin, warm water, soap, four washcloths, one towel, barrier, gloves, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Raise one side rail of the bed. Check the resident’s mobility and their preferred side to lie on.
Put on gloves.
Raise the bed height if needed.
Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water
temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
Turn the resident or raise the hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their
buttocks.
Expose the perineum only.
Use water and a soapy washcloth.
If the resident is not circumcised, gently move the foreskin away from their urethra toward the base of the penis.
Using a clean portion of the first washcloth, start from the urethra and clean in a circular motion toward their scrotum.
Using a clean portion of the first washcloth, clean one groin fold and the scrotum.
Using a clean portion of the first washcloth, clean the other groin fold and the other side of scrotum.
Put the first washcloth in a linen bag.
Using the second clean washcloth, rinse from the urethra in a circular motion toward the scrotum.
Using a clean portion of the second washcloth, rinse one groin fold and the scrotum.
Using a clean portion of the second washcloth, rinse the other groin fold and the other side of the scrotum.
Put the second washcloth in the linen bag.
Avoid overexposure throughout the procedure.
Pat dry.
If uncircumcised, gently return the foreskin toward the urethra.
Cover the exposed area with the bath blanket.
Assist the resident to turn onto their side away from you and ask the resident to hold onto the raised side rail.
Using the third clean washcloth, apply water and soap.
Using a clean portion of the third washcloth, clean one side of the buttock wiping away from the urethra.
Using a clean portion of the third washcloth, clean the other side of the buttock wiping away from the urethra.
Using a clean portion of the third washcloth, clean the rectal area wiping away from the urethra.
Put the third washcloth in the linen bag.
Using the fourth washcloth, rinse one side of the buttock wiping away from the urethra.
Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the urethra.
Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from the urethra.
Put the fourth washcloth in the linen bag.
Pat dry.
Safely remove the waterproof pad from under the buttocks.
Remove the gloves, turning them inside out.
Perform hand hygiene.
Position the resident on his back.
Put on clean gloves.
Dispose of soiled linen in the designated laundry hamper.
Empty the equipment.

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 Rinse the equipment.
Dry the equipment.
Return the equipment to storage.
Remove the gloves, turning them inside out.
Dispose of gloves in an appropriate container.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating male perineal care:

Perineal Care - Male

1. Chippewa Valley Technical College. (2022, December 3). Perineal Care (Male). [Video]. YouTube. Video licensed under CC
BY 4.0. https://youtu.be/n3Ed36YSz9w ↵

This page titled 5.19: Skills Checklist- Perineal Care (Male) is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by
Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available
upon request.

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5.20: Skills Checklist- Oral Care
1. Gather Supplies: Gloves, toothbrush, toothpaste, emesis/oral basin, cup of water, clothing protector (towel), barrier (paper
towel), and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Place all supplies on a barrier.
Put on gloves.
If the resident is in bed, elevate the head of the bed if it is permissible per the care plan.
Cover the resident’s chest with a towel to keep their clothing or gown clean.
Wet the toothbrush in the sink or in a cup of water.
Apply a small amount of toothpaste to the toothbrush.
Brush the resident’s teeth, including the inner, outer, and chewing surfaces of all upper and lower teeth.
After each quadrant of the mouth (i.e., lower right, lower left, upper right, or upper left), allow the resident to rinse with
water and spit into an emesis basin if needed.
Clean the resident’s tongue being careful not to cause the resident to gag.
Assist the resident in rinsing their mouth.
Wipe the resident’s mouth with the towel on their chest.
Remove the towel and place it in a linen bag.
Empty the emesis basin.
Rinse the emesis basin.
Dry the emesis basin.
Rinse the toothbrush.
Return the equipment to storage.
Remove the gloves, turning them inside out.
Dispose of the gloves in an appropriate container.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any oral issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating oral care:

5.20.1 https://med.libretexts.org/@go/page/70348
 Oral Care

1. Chippewa Valley Technical College. (2022, December 3). Oral Care. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/SQEjgHODEz0 ↵

This page titled 5.20: Skills Checklist- Oral Care is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra
Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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5.21: Skills Checklist- Denture Care
1. Gather Supplies: Gloves, denture brush, denture toothpaste if available, dentures, denture cup, denture cleansing tablet if
desired, emesis/oral basin, oral swab, cup of water, clothing protector (towel), barrier (paper towel), sink liner (paper towel or
[1]
washcloth), and linen bag or hamper. See Figure 5.26 at the end of this checklist for an image of an oral swab.
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Place all supplies on a barrier.
Place a clothing protector on the resident.
Line the sink with a washcloth or paper towel.
Remove dentures from the cup or remove them from the resident’s mouth and place them in the denture cup or emesis basin.
Handle the dentures carefully to avoid damage or contamination.
Wet the denture brush and apply denture toothpaste if available. Water alone is acceptable to clean dentures if toothpaste is
not available.
Thoroughly brush the inner, outer, and chewing surfaces of each denture.
Rinse the dentures using clean, cool water and place them on a clean barrier or in an emesis basin.
Rinse the denture cup.
Place the dentures in a rinsed cup.
Wet an oral swab and gently clean all surfaces of the resident’s gums and tongue.
Allow the resident to rinse and spit into the emesis basin.
Place the dentures in the resident’s mouth if desired.
Wipe the resident’s mouth and remove the clothing protector, placing it in an appropriate container.
In the evening, place the dentures in the denture cup and add cool, clean water to the denture cup to cover the dentures.
Put a denture cleansing tablet in the cup, if desired.
Rinse the equipment (denture brush and emesis basin).
Return the equipment to storage.
Discard the protective lining in an appropriate container.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any oral issues or changes noted with the resident.

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 Figure 5.26 Oral Swab
View a YouTube video[2] of an instructor demonstrating denture care:

Denture Care

1. "Oral Swab" by Landon Cerny is licensed under CC BY 4.0 ↵

2. Chippewa Valley Technical College. (2022, December 3). Denture Care. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/kDWlh3lRGnk ↵

This page titled 5.21: Skills Checklist- Denture Care is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra
Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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5.22: Skills Checklist- Preparing Clients for Meals and Assisting With Feeding
1. Gather Supplies: Clothing protector, meal, diet card, eating utensils, sanitizer or soapy and wet washcloths
2. Routine Pre-Procedure Steps:
Knock on the resident’s door unless they are in the dining room.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Explain the procedure to the resident.
3. Procedure Steps:
Verify the name on the diet card matches the resident.
Verify the diet, diet texture, and liquid consistency matches the diet card.
Position the resident in an upright position, at least 45 degrees.
Place a clothing protector on the resident if desired (e.g., a paper or cloth towel or a large napkin).
Ask the resident if they would like oral care before eating.
Assist the resident to clean their hands before feeding using sanitizer or soapy and wet washcloths.
Position yourself at eye level facing the resident.
Describe the foods and fluids being offered to the resident.
Offer small amounts of food at a reasonable rate.
Offer fluids frequently.
Allow the resident time to chew and swallow.
Wipe the resident’s face whenever necessary.
Continue to alternate foods and fluids until the resident indicates they are full.
Clean the resident’s face and hands.
Ask the resident if they would like oral care.
Leave the resident with their head elevated at least 30 degrees.
4. Post-Procedure Steps:
Perform hand hygiene.
Record the intake as a percentage of total solid food eaten.
Record the sum of estimated fluid intakes in mL or cc.
Check for resident comfort and ask if anything else is needed.
If in the resident’s room, ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any feeding issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating preparing clients for meals and assistance with feeding:

Preparing Clients for Meals and Assista…

Assista…

5.22.1 https://med.libretexts.org/@go/page/70350
 1. Chippewa Valley Technical College. (2022, December 3). Preparing Clients for Meals and Assistance With Feeding. [Video].
YouTube. Video licensed under CC BY 4.0. https://youtu.be/Yt3EelUdy60 ↵

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authored, remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts
platform; a detailed edit history is available upon request.

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5.23: Skills Checklist- Choking Maneuver
1. Call out for help or tell another staff member to get the nurse if you think a resident is choking. If no nurse is available, direct
someone to call 911 while proceeding with the following steps.
2. Until help arrives, stand behind the victim with one leg forward between the victim’s legs.
3. For a child, move down to their level and keep your head to one side.
4. Reach around their abdomen and locate the navel.
5. Place the thumb side of your fist against their abdomen just above the navel.
6. Grasp your fist with your other hand and thrust inward and upward into the victim’s abdomen with quick jerks.
7. For a responsive pregnant victim, any victim you cannot get your arms around, or for anyone in whom abdominal thrusts are
not effective, give chest thrusts while standing behind them. Avoid squeezing the ribs with your arms.
8. Continue thrusts until the victim expels the object or becomes unresponsive.
9. If the person becomes unconscious, notify the nurse. If no nurse is available, call 911.
View a YouTube video[1] of an instructor demonstrating the choking maneuver:

Choking Maneuver

1. Chippewa Valley Technical College. (2022, December 3). Choking Maneuver. [Video]. YouTube. Video licensed under CC BY
4.0. https://youtu.be/HMtwmw5Vaoo ↵

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Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available
upon request.

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5.24: Skills Checklist- Catheter Care
1. Gather Supplies: Basin, warm water, soap, two washcloths, one towel, barrier, gloves, and linen bag or hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water
temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
Raise the bed height to a working height.
Expose only the urethra and catheter.
Follow the tubing from the resident toward the drainage bag, ensuring that the tubing is at a lower level as it goes toward the
bag. Be sure no kinks or elevation can cause backflow to the bladder.
Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, or disposable pad) under their
buttocks.
Use the first washcloth with soap and water to carefully wash around the catheter where it exits the urethra.
Hold the catheter where it exits the urethra with one hand.
While holding the catheter, clean 3-4 inches down the catheter tube.
Clean with strokes moving away from the urethra.
Use a clean portion of washcloth for each stroke.
Put the soiled first washcloth in the linen bag.
Wet the second washcloth and rinse, using strokes only away from the urethra while continuing to hold the catheter where it
exits the urethra.
Rinse using a clean portion of washcloth for each stroke.
Put the soiled second washcloth in the linen bag.
Pat dry with a towel.
Do not allow the tube to be pulled at any time during the procedure.
Replace the gown over the resident’s perineal area.
While wearing gloves, empty the basin.
Rinse the basin.
Dry the basin.
Return the equipment to storage.
Dispose of soiled linen in a designated laundry hamper.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating catheter care:

5.24.1 https://med.libretexts.org/@go/page/70352
 Catheter Care

1. Chippewa Valley Technical College. (2022, December 3). Catheter Care. [Video]. YouTube. Video licensed under CC BY 4.0.
https://youtu.be/pIM5rRt9s-w ↵

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Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
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5.25: Skills Checklist- Emptying Catheter Drainage Bag
1. Gather Supplies: Gloves, two barriers, graduated cylinder, and alcohol swab
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Place a barrier (e.g., paper towel or disposable pad) on the floor under the drainage bag.
Place the graduated cylinder on the barrier.
Open the drain to allow the urine to flow into the graduated cylinder.
Avoid touching the tip of the tubing to the sides of the graduated cylinder.
Close the drain.
Wipe the drain with an alcohol wipe.
Wipe the drain holder, if present, with an alcohol wipe.
Replace the drain into the holder.
Place a clean barrier on a level, flat surface.
Place the graduated cylinder on the barrier.
With the graduated cylinder at eye level, read the amount of output.
Note the characteristics (i.e., color, clarity, sediment, or unusual odor) of the urine.
Empty the urine in the graduated cylinder into the toilet.
Rinse the graduated cylinder and empty it into the toilet.
Return the equipment to storage.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document urinary output in mL and report any issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating emptying catheter drainage bag:

Emptying a Urinary Catheter Drainage B…

B…

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5.26: Skills Checklist- Assisting With a Bedpan
1. Gather Supplies: Gloves, bedpan, barrier, and toilet tissue
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Put on gloves.
Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, disposable pad) under their
buttocks.
Position the resident on the bedpan/fracture pan correctly. The deeper portion of the bedpan should be directed toward their
toes, and the resident should be centered on the bedpan. For fracture bedpans, the handle should be directed toward their
toes.
Raise the head of the bed to a comfortable level.
Cover the resident with linens or a bath blanket.
Leave toilet tissue within reach of the resident.
Leave the call light within reach of the resident.
Wait nearby allowing for resident privacy.
When the resident signals, return and assist the resident to perform hand hygiene.
Discard the soiled linen in the designated laundry hamper.
Gently remove the bedpan/fracture pan.
Assist with perineal care.
Empty the bedpan into the toilet or into a graduated cylinder if output is being recorded. Note the amount and characteristics
(i.e., color, clarity, sediment, or unusual odor) of the urine. Empty the urine from the graduated cylinder used into the toilet.
Rinse the equipment used and empty the rinse water into the toilet.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document urinary output in mL and report any issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating assisting with a bedpan:

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 Assisting with a Bedpan

1. Chippewa Valley Technical College. (2022, December 3). Assisting with a Bedpan. [Video]. YouTube. Video licensed under CC
BY 4.0. https://youtu.be/WCg57s4HGhc ↵

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5.27: Skills Checklist- Assisting With a Urinal
1. Gather Supplies: Gloves, urinal, and barrier
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Assist the resident to their preferred position of comfort and mobility status (e.g., seated on the side of the bed, lying in bed,
or standing).
Place the urinal with the shaft of the penis well within the opening. Keep the urinal level to prevent urine spillage while the
resident is urinating. If the resident has discomfort, a washcloth can be placed around the rim of the urinal to prevent skin
issues.
Provide privacy while the resident voids.
Place a barrier on a flat surface.
Place the urinal on the barrier.
With the urinal at eye level, read the amount of urine and note its characteristics (i.e., color, clarity, sediment, or unusual
odor).
Empty the urinal into the toilet.
Rinse the urinal and empty the rinse water into the toilet.
Return the urinal to storage.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document urinary output in mL and report any skin issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating assisting with a urinal:

Assisting With a Urinal

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 1. Chippewa Valley Technical College. (2022, December 3). Assisting with a Urinal. [Video]. YouTube. Video licensed under CC
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5.28: Skills Checklist- Changing Incontinence Brief
1. Gather Supplies: Gloves and brief
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
If the resident is in bed, raise one side rail.
Moving to the opposite side of bed, assist the resident to raise their hips or turn towards the side rail. Remove the soiled
brief.
Remove the gloves, turning them inside out.
Perform hand hygiene.
Put on gloves.
Assist with perineal care.
Remove the gloves, turning them inside out.
Perform hand hygiene.
Put on gloves.
Place a new brief under the resident’s buttocks and center the brief. Gently tuck the tabs under the resident.
Assist the resident to roll onto their back.
Position the brief over the front of the resident and secure the brief with tabs.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document output from the soiled brief and report any skin issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating changing incontinence brief:

Changing Incontinence Brief

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 1. Chippewa Valley Technical College. (2022, December 3). Changing Incontinence Brief. [Video]. YouTube. Video licensed
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5.29: Skills Checklist- Dressing A Client Who Needs Total Assistance
1. Gather Supplies: Resident clothing, socks and footwear, and hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Raise the bed height.
Keep the resident covered while removing their gown.
Remove the gown from the unaffected (most mobile) side first.
Place the used gown in a designated laundry hamper.
Ask the resident their preferences for desired clothing.
Start dressing them on their affected (least mobile) side first. Insert their hand through the sleeve of their shirt and grasp the
hand of the resident to guide it through the sleeve.
Put pants on both legs, starting with the affected (least mobile) side first. If the resident is able, assist them to raise their
buttocks. If they are unable to raise their hips, put the side rail on their unaffected (most mobile) side up. Assist the resident
to turn towards the side rail. Pull the pants over their buttocks and up to their waist.
While still on the unaffected (most mobile) side, tuck the resident’s shirt underneath their unaffected side.
Assist the resident onto their back.
Raise the side rail if the resident is unable to lift their hips.
Move to the unaffected side of the resident.
Place their unaffected arm in the shirt sleeve, grasping the hand of the resident. Finish putting on their shirt by buttoning and
zipping closures.
Assist the resident to turn onto their affected side and pull their pants up to their waist.
Return the resident to lying on their back.
Put on the resident’s socks. Draw the socks up the resident’s foot until they are smooth.
Put on the resident’s nonskid footwear by slipping each nonskid footwear on the resident’s feet.
Leave only when the resident is properly dressed.
4. Post-Procedure Steps:
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating dressing a client who needs total assistance:

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 Dressing a Client Who Needs Total Assi…
Assi…

1. Chippewa Valley Technical College. (2022, December 3). Dressing a Client Who Needs Total Assistance. [Video]. YouTube.
Video licensed under CC BY 4.0. https://youtu.be/StcnLjYQBtY ↵

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5.30: Skills Checklist- Shaving With an Electric Razor
1. Gather Supplies: Gloves, clothing protector (towel), razor, and hamper
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Sit the resident upright and place a clothing protector over their chest.
Hold the shaver at a right angle to the resident’s face, using your free hand to pull their skin taught as you shave. This will
minimize snagging and the risk of cutting the resident.
Shave all areas of the face and neck per resident preference.
Gather the clothing protector so their whiskers do not fall onto their clothing.
Place the clothing protector in the designated hamper.
Clean the razor per facility guidelines and charge or plug it in.
Remove the gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes noted with the resident.
View a YouTube video[1] of an instructor demonstrating shaving with an electric razor:

Shaving With an Electric Razor

1. Chippewa Valley Technical College. (2022, December 3). Shaving with an Electric Razor. [Video]. YouTube. Video licensed
under CC BY 4.0. https://youtu.be/ShawTlxf1o8 ↵

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5.31: Learning Activities

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5.32: V Glossary
Activities of daily living (ADLs): Hygiene, grooming, dressing, fluid and nutritional intake, mobility, and elimination needs of
clients.
A.M. care: Personal care performed in the morning.
Aspiration: Inadvertently breathing fluid or food into the airway instead of swallowing it.
Clock method: A method used with clients with visual impairments to describe where the food on their plate is located. For
example, state, “Your mashed potatoes are at 10 o’clock, the green beans are at 2 o’clock, and the meat loaf is at 6 o’clock on your
plate.”
CLOWD: An acronym to consider after providing personal care but before leaving the room that stands for Comfort; Light, Lock
and Low; Open; Wash; and Document.
Colostomy: A surgically placed opening when a client’s colon function is impaired. A piece of the colon is diverted to an artificial
opening in the abdominal wall called a stoma, and feces is collected in a pouch.
Commode: A movable device with a bucket underneath the seat that is used for elimination when the client has difficulty getting
to the bathroom.
Complete bed bath: A bath provided in bed for clients who have difficulty getting out of bed, are experiencing excessive pain, or
have other physical or cognitive issues that make other types of bathing less tolerable.
Grooming: Maintaining a resident’s appearance through shaving, hair, and nail care.
Hygiene: Keeping the body clean and reducing pathogens by performing tasks such as bathing and oral care.
Impaired skin integrity: Skin that is damaged or not healing normally. An example of impaired skin integrity is a pressure injury
(also called a bedsore or pressure ulcer) with damage to the skin and surrounding tissue.
Incontinence briefs or pads: Disposable products used for clients with little to no control over bladder or bowel function.
Partial bath: Washing the face, underarms, arms, hands, and perineal area. Partial baths are given daily to maintain hygiene. They
preserve skin integrity by not drying out skin with excessive soap and water use.
Perineal: The genital and anal area.
Personal care: Care that a client needs to maintain hygiene, well-being, self-esteem, and dignity.
Person-centered care: A care approach that considers the whole person, not just their physical and medical needs. It also refers to
a person’ autonomy to make decisions about their care, as well as participate in their own care.
P.M. care: Personal care performed in the evening.
Pureed diet: A diet order indicating all food is blended to smooth consistency.
Routine cares: Personal cares provided to every resident every day, such as assisting them in getting dressed for breakfast.
Sepsis: Life-threatening infection that has spread throughout the body.
SKWIPE: An acronym to consider before providing cares to clients that stands for Supplies, Knock, Wash, Introduce, Privacy, and
Explain.
Timed voiding: Encourages the patient to urinate on a set schedule.
Urge incontinence: A condition where as soon as the person feels the need to empty their bladder they have very little time before
urine escapes.
Urinary catheter: A device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection
bag.
Urinary tract infection (UTI): A common infection that occurs when bacteria, typically from the rectum, enter the urethra and
infect the bladder or kidneys.
Urostomy: A surgically placed opening to collect urine from a person’s ureters when their bladder is diseased or has been
removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag.

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Wet voice: Vocalization with sounds as if food or fluids remain in the mouth or throat.

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 CHAPTER OVERVIEW

6: Provide for Basic Nursing Care Needs

6.1: Introduction to Provide for Basic Nursing Care Needs
6.2: Nutrition and Fluid Needs
6.3: Pain
6.4: Comfort Measures
6.5: Effects of Prescribed Routine Medications
6.6: End-of-Life Care
6.7: Postmortem Care
6.8: Skills Checklist- Topical Medications
6.9: Learning Activities
6.10: VI Glossary

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1
6.1: Introduction to Provide for Basic Nursing Care Needs
Learning Objectives
Carry out the basic nursing skills required for the nursing assistant
Adapt care to meet the physical needs of the aging client
Apply heat and cold applications
Administer nonprescription (OTC) medications
Define the principles of nutrition and fluid needs
Provide client comfort measures
Assist with end-of-life care for the dying client
Assist with postmortem care
Recognize the general effects of prescribed routine medications

The general scope of practice for nursing assistants (NAs) relates to helping individuals with their activities of daily living (ADLs),
including facilitating fluid and nutritional intake. NAs also complete actions that provide comfort and increase clients’ quality of
life. Quality of life refers to the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life
events.
Nurses may delegate actions to nursing assistants that provide comfort to residents, such as application of nonprescription, topical
medications or heat and cold treatments. Nursing assistants may also provide care to residents in special situations, such as end-of-
life care or postmortem care. End-of-life care is a term used to describe care provided when death is imminent and life expectancy
is limited to a short number of hours or days. Postmortem care refers to care provided after death has occurred through transfer to
a morgue or funeral provider. Knowing how to safely and respectfully implement these delegated interventions is essential.

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6.2: Nutrition and Fluid Needs
Nursing assistants (NAs) help clients meet their nutritional and fluid needs as they assist them with their activities of daily living. Let’s begin by reviewing the anatomy and physiology of the
gastrointestinal system.

Anatomy and Physiology of the Gastrointestinal System

The gastrointestinal system (also referred to as the digestive system) is responsible for several functions, including digestion, absorption, and immune response. Digestion begins at the mouth, where
chewing of food occurs. This is called mechanical digestion. If food is not broken down mechanically by the teeth, it is very difficult to digest, and it also increases the risk of choking. If there are
any concerns with missing or broken teeth, dentures that don’t fit well, or any pain or open areas in the mouth, the NA should report these concerns to the nurse immediately.
After food is chewed and swallowed, it goes into the stomach via the esophagus. Involuntary movement, called peristalsis, allows the food to enter the stomach to mix with acidic gastric juices. The
breaking down of food with these acids is called chemical digestion. From the stomach, the liquid food (called chyme) passes through the small and large intestine where nutrients and water are
[1] [2]
absorbed into the bloodstream. Waste products are condensed into feces and excreted through the anus. , More information on the structure and function of the digestive system will be covered in
Chapter 11.
Appropriate food and fluid intake are essential to good health, so anything that potentially decreases a client’s appetite must be addressed. For example, all five senses decline in functioning to some
extent in older adults. It is important for the NA to provide accommodations that address these declines in sensory function that can impact food intake and overall health. Enhancing food intake in
older adults with altered sensory function includes the following accommodations:
Vision
If the resident is known to wear glasses, ensure they are wearing them, and the lenses are clean. Seeing food often stimulates the desire to eat.
Explain what is on the meal tray if the client has significant visual impairment. It is helpful to use the “clock method,” such as, “On your plate, your peas are at 3 o’clock, your roast beef is at
6 o’clock, and your mashed potatoes are at 9 o’clock.”
If a resident has a pureed diet order, review their menu so you can describe each type of food in an appealing manner.
Make meals look as attractive as possible. Take food off trays and avoid using plastic utensils and disposable cups whenever possible so the resident feels as if they are having a meal at
home.
Hearing
If the resident has hearing aids, ensure they are in place, charged, and functioning so they can hear you describe the food.
Ask if music is preferred during mealtime.
When seating residents in a public eating area, ensure they are seated with others with similar cognitive status so they may enjoy conversation while eating.
Touch
Encourage the resident to eat as independently as possible by using adaptive silverware or other meal aids. Occupational therapists can assess the needs of the resident and provide adaptive
equipment.
If utensils can’t be held by the resident, try using finger foods such as fruit, bread, or crackers.
Smell
If possible, dietary staff should prepare meals near resident rooms because the aroma of cooking food may increase hunger.
If a client is eating a meal in their room, clear the room of unpleasant odors or sights. For example, empty the trash can if it has soiled incontinence products, and empty urinals that may be
sitting on side tables.
Taste
Check the diet order. If the order permits, ask residents if they prefer seasoning or condiments.
Ensure hot foods are served hot and cold foods are served cold. Judge the temperature of the food by placing your hand above the food to sense heat, but do not touch the food directly with
your hand. Rewarm hot foods that have cooled.
If the resident does not like the meal choice, find an alternative food that appeals to them.
Refer to the “Assisting With Nutrition and Fluid Needs” section and the checklist “Preparing Clients for Meals and Assisting With Feeding” in Chapter 5 for specific steps and additional insight on
feeding a dependent client.

Macronutrients
In hospitals and long-term care facilities, the dietician assesses clients periodically to ensure that their nutritional and fluid needs are met. However, when providing care in a group home, assisted
living, or home health, NAs are often responsible for creating meals. It is important to understand basic nutritional concepts so you can address your clients’ nutritional needs.
Macronutrients make up most of a person’s diet and provide energy, as well as essential nutrient intake. Macronutrients include carbohydrates, proteins, and fats. However, too many
macronutrients without associated physical activity cause excess nutrition that can lead to obesity, cardiovascular disease, diabetes mellitus, kidney disease, and other chronic diseases. Conversely,
[3]
too few macronutrients contribute to nutrient deficiencies and malnourishment.
Carbohydrates are sugars and starches and are an important energy source. Each gram of carbohydrates provides four calories. Carbohydrates break down into glucose and raise blood sugar levels.
Diabetics should limit carbohydrate intake to maintain blood sugar levels in a healthy range.
Proteins are peptides and amino acids that provide four calories per gram. Proteins are necessary for tissue repair and function, growth, energy, fluid balance, clotting, and the production of white
blood cells.
Fats consist of fatty acids and glycerol and are essential for tissue growth, insulation, energy, energy storage, and hormone production. Each gram of fat provides nine calories. While some fat intake
[4]
is necessary for energy and the absorption of fat-soluble vitamins, excess fat intake contributes to heart disease and obesity. Due to its high-calorie content, a little fat goes a long way.
Fats are classified as saturated, unsaturated, and trans fatty acids. Saturated fats come from animal products, such as butter and red meat (e.g., steak). Saturated fats are solid at room temperature.
[5]
Recommended intake of saturated fats is less than 10% of daily calories because saturated fat raises cholesterol and contributes to heart disease.
Unsaturated fats come from oils and plants, although chicken and fish also contain some unsaturated fats. Unsaturated fats are healthier than saturated fats. Examples of unsaturated fats include
olive oil, canola oil, avocados, almonds, and pumpkin seeds. Fats containing omega-3 fatty acids are considered polyunsaturated fats and help lower cholesterol levels. Fish and other seafood are
[6]
excellent sources of omega-3 fatty acids.
Trans fats are fats that have been altered through a hydrogenation process, so they are not in their natural state. During the hydrogenation process, fat is changed to make it harder at room
temperature and have a longer shelf life. Trans fats are found in processed foods, such as chips, crackers, and cookies, as well as in some margarines and salad dressings. Minimal trans-fat intake is
[7]
recommended because it increases cholesterol and contributes to heart disease.

Choosing Food Groups to Meet Macronutrient Needs

[8]
Good resources for healthy nutritional choices are the USDA’s “My Plate” guidelines. By using a plate as a visual, sections on the plate illustrate general amounts of the different types of food
[9]
groups that should be eaten every meal, including fruits and vegetables, grains, protein, and dairy. See Figure 6.1 for an image of the USDA’s “My Plate” guidelines.

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 Figure 6.1 My Plate
About half the plate should be fruits and vegetables that provide many nutrients, as well as fiber for healthy bowel elimination. Fruits and vegetables are low in fat and calories and have no
cholesterol. Fresh fruits and vegetables are the best choice, but frozen options have similar nutritional value. Frozen produce can also be more cost-effective because it doesn’t spoil and can save
time as the food is already cleaned and chopped. A variety of colors of fruits and vegetables not only makes the plate visually appealing, but also provides the greatest array of nutrients.
About 25% of the plate should be grains. Pasta, cereal, and bread are sources of grains. Types of grains include wheat, corn, rice, oats, barley, and quinoa. Grains are low in fat and cholesterol but
have high carbohydrate and fiber content. The fiber content in grains can be helpful in preventing constipation and lowering cholesterol. Due to the high carbohydrate content of grains, they may
need to be limited for clients with diabetes.
The remaining 25% of the plate should contain protein sources. Common proteins include soy, quinoa, eggs, fish, meat, nuts and seeds, legumes (beans), and dairy products. Just as with the other
food groups, a variety of protein selections provides the most nutrients. Red meat can contain a lot of fat and cholesterol, so lean cuts are preferred for heart health. Fish, especially salmon, has
healthy fat and should be consumed twice weekly. Nuts, seeds, and legumes are low in saturated fat and high in fiber, which also make them a good choice for protein.
Dairy choices are important for calcium intake that aids in bone health. Calcium intake is important for older adults because they naturally retain less calcium and are at higher risk for bone
fractures. Dairy products include milk, lactose-free milk, soy milk, buttermilk, cheese, yogurt, and kefir. Sour cream and cream cheese are not considered dairy items in terms of nutritional benefits.
Adults should consume about three cups of dairy per day.
Choosing whole foods that are unprocessed, or as close to their original form as possible, is important to feeling full and stabilizing blood sugar because it takes longer to digest unprocessed foods.
Think about eating an apple as compared to drinking apple juice. The whole apple will take a long time to chew and chemically break down to chyme, whereas the juice is ready to move through the
digestive tract immediately. Eating whole foods can also reduce salt, fat, and sugar intake because they have no additives and can keep blood pressure, blood sugar, and cholesterol levels lower.

Read additional information about My Plate guidelines at https://www.myplate.gov/.

Fluid Intake
[10]
Fluid intake comes from both liquids and foods. For example, most fruits and vegetables contain a lot of water, so they contribute to fluid intake. See Table 6.2 for water content in various foods.
Table 6.2 Water Content in Foods

Percentage Food Items

90-99 Nonfat milk, cantaloupe, strawberries, watermelon, lettuce, cabbage, celery, spinach, squash

80-89 Fruit juice, yogurt, apples, grapes, oranges, carrots, broccoli, pears, pineapple

70-79 Bananas, avocados, cottage cheese, ricotta cheese, baked potato, shrimp

60-69 Pasta, legumes, salmon, chicken breast

50-59 Ground beef, hot dogs, steak, feta cheese

40-49 Pizza

30-39 Cheddar cheese, bagels, bread

20-29 Pepperoni, cake, biscuits

10-19 Butter, margarine, raisins

1-9 Walnuts, dry-roasted peanuts, crackers, cereals, pretzels, peanut butter

0 Oils, sugars

The average fluid intake in adults per day is 1.5 liters of fluids with additional 700 milliliters (mL) of water gained from solid foods. About 2.5 liters of fluid are excreted daily in adults in urine,
[11]
feces, respiration, and other body fluids like sweat and saliva.
There is some debate over the amount of water required to maintain health. There is no consistent scientific evidence proving that drinking a particular amount of water improves health or reduces
[12]
the risk of disease. Additionally, the amount of fluids a person consumes daily is variable and based on their climate, age, physical activity level, and kidney function.
Our bodies are constantly trying to balance our fluid volume using the physiological mechanisms of thirst and urine output. The “thirst center” is contained within the hypothalamus, a portion of the
[13]
brain that lies just above the brain stem. As people age, their thirst mechanism becomes less responsive, causing a higher risk of dehydration. See Figure 6.2 for an illustration of the thirst
response. Thirst occurs in the following sequence of physiological events:
Receptors in the kidney, heart, and hypothalamus detect decreased fluid volume or increased sodium concentration in the blood.
Hormonal and neural messages are relayed to the brain’s thirst center in the hypothalamus.
The hypothalamus sends neural signals stimulating the conscious thought to drink.
Fluids are consumed.
Receptors in the mouth and stomach detect mechanical movements involved with fluid ingestion.
[14]

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 [14]
Neural signals are sent to the brain and the thirst mechanism is shut off.

Figure 6.2 Thirst Response

Thirst is a subconscious physiological mechanism to stimulate water intake. However, actual fluid intake is controlled by conscious eating and drinking habits that are influenced by cognitive,
social, and cultural factors. For example, some individuals have a habit of drinking a glass of orange juice, coffee, or milk every morning before going to school or work. Conversely, older adults
often have decreased fluid intake due to physical or cognitive challenges in obtaining or drinking fluids. For this reason, older adults often require assistance to maintain a healthy intake of fluids.
Due to the decreased thirst response in older adults, it is important to prevent dehydration by encouraging fluid intake even when they don’t feel thirsty. Dehydration can lead to confusion, falls, and
[15]
bladder infections. Signs of dehydration include the following :
Dry mouth or other mucous membranes
Dry skin or skin that does not return to normal shape when gently pinched
Dark urine or urine amounts smaller than 200-300 mL
Headache
Dizziness
Rapid heart rate
Low blood pressure
If signs or symptoms of dehydration are noted, these concerns should be reported to the supervising nurse, and fluid intake should be encouraged as tolerated.
In hospitals and long-term care facilities, dieticians often determine the amount of daily fluid intake for clients. Fluid restrictions may be prescribed by the health care provider based on the client’s
medical condition. Fluid restrictions are further discussed in the following “Modified Diets” subsection.

Cultural and Religious Considerations With Nutritional Intake

Cultural and religious beliefs often influence a client’s food selection and food intake. Dieticians and nurses assess a client’s cultural and religious preferences on admission to a facility, but NAs
should continually ask clients about their food and fluid preferences. A particular diet should never be assumed based on a client’s stated culture or religion.
Cultural beliefs may affect the types of food eaten, as well as when they are eaten. Some foods may be restricted due to cultural beliefs or religious rituals, whereas other foods may be viewed as
part of the healing process. For example, some individuals choose not to eat pork because of cultural or religious beliefs that consider pork unclean. Other individuals choose to eat “kosher” food
because its method of preparation fits with their religious guidelines. Additionally, some individuals avoid eating during certain times. For example, some clients’ religious beliefs encourage fasting
[16]
on religious holidays from sunrise to sunset, whereas other individuals avoid eating meat during their religious season of Lent.

Modified Diets
Some individuals require limitations of certain foods or fluids due to medical circumstances, illnesses, or chronic diseases. For these reasons, the provider may order a modified diet, also referred to
as a “therapeutic diet,” based on recommendations from a dietician. A modified diet is any diet altered to include or exclude certain components. For example, a client may have a modified diet
order due to an upcoming test or procedure, a specific medical condition like diabetes, an allergy like a gluten allergy, or to lose weight.
As previously discussed in Chapter 5, it is critical for the NA to verify the diet orders for every client and then verify the food and fluids on their meal trays are correct based on the diet order. Here
are some of the most common diet orders:
Low-Sodium: Salt intake is commonly restricted for individuals with high blood pressure, heart failure, and kidney disease. Salt substitutes may be offered and high sodium condiments, such as
ketchup, soy, barbecue and steak sauces, are avoided. This diet is commonly abbreviated as Low NA (sodium) or NAS (No added salt/sodium).
Low-Fat: A low-fat diet is commonly prescribed for individuals with high cholesterol, heart disease, or arterial circulation problems. High-fat dairy and meat products, fried foods, desserts, and
baked goods are avoided. However, healthy fats can be consumed from plant-based sources such as olive oil, nuts, avocados, and salmon.
Low-Residue or Low-Fiber: Low-residue or low-fiber diets are commonly prescribed for individuals with bowel disorders. Fiber is found in grains, seeds, fruits, and vegetables, so these food
choices are typically avoided.
Diabetic or Carb-Controlled: Carb-controlled diets are typically prescribed for individuals with diabetes to help keep their blood sugar in a healthy range. This diet includes reduced intake of
carbohydrates, especially from processed sources such as juices, starches such as potatoes and bread, and cereal or pasta that is not whole grain. Good carbohydrate sources include whole fruits
and vegetables. Fat intake may also be restricted because it can elevate blood sugar levels. This diet is commonly abbreviated as CHO or CCHO. Many clients with diabetes have orders for a
bedside blood glucose test before eating; ensure this test is completed and/or reported to the nurse.
Gluten-Free: The gluten-free diet is typically prescribed for people with gastrointestinal conditions such as celiac disease or irritable bowel syndrome because their symptoms are aggravated by
gluten. Gluten is found in wheat, rye, and barley, so rice, oats, and quinoa are good substitutes. There are many gluten-free pasta, cereal, and bread products available.
Lactose-Free: Lactose is removed from the diet for individuals who are lactose intolerant. Lactose is found in milk and dairy products. Soy, almond, or rice milk are good substitutes that
provide calcium.
Fluid Restriction: Fluid restriction orders may be temporary, such as several hours before surgery, or permanent, such as for clients with kidney failure or heart failure. The provider prescribes
the amount of fluid a person should consume in one day. In a hospital or facility, this amount is typically split across shifts based on meal and snack times while also taking into consideration
fluids consumed with medications. Clients on fluid restrictions will also have their fluid intake and output tracked and documented daily as previously discussed in Chapter 5.
NPO: NPO is a common medical abbreviation referring to “nothing by mouth.” NPO may be a temporary order, such as 8-12 hours before surgery, or a permanent order, such as for an
individual with a permanent feeding tube due to dysphagia. Dysphagia refers to difficulty swallowing that can cause aspiration of liquids and food into one’s lungs and lead to life-threatening
pneumonia. Individuals with severe dysphagia may never be able to eat or drink anything without risking pneumonia. Their nutrition is typically given through a permanent tube placed directly
into their stomach (i.e., a PEG tube), or if it is a temporary condition, a tube is inserted through their nose into the stomach (i.e., an NG tube). Residents who are NPO do not typically desire to
go to the dining room during meals because they can’t eat a regular diet, but be sure to ask their preference.

Diet Texture
In addition to modified diet orders regarding the content of the food choices, the texture of the food may also be modified based on the chewing and swallowing ability of the resident. Common
orders for diet textures for residents include regular, mechanical soft, or pureed:

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Regular Diet: Regular diets include any texture of food.
Mechanical Soft: Mechanical soft diets include food that is soft or easily mashed with a utensil. Meat is ground to make chewing easier. Fruits and vegetables are boiled to soften any skin, and
[17]
sometimes it is removed. See Figure 6.3 for an image of a mechanical soft diet.

Figure 6.3 Example of a Mechanically-Soft Meal. Used

with permission.
[18]
Pureed: Pureed diets include food that is blended to the consistency of a thick paste. See Figure 6.4 for an image of a pureed diet.

Figure 6.4 Example of Pureed Food. Used with

permission.

Liquid Consistency
Clients may require a specific type of liquid consistency if they have dysphagia and increased risk for aspiration. The flap that covers the trachea and prevents liquids from entering the lungs when
swallowing is called the epiglottis. If the epiglottis loses muscle tone, liquid can seep around it into the lungs and cause aspiration pneumonia. Signs of possible dysphagia are when a client
continually coughs or clears their throat while eating or drinking. These signs should be reported immediately to the nurse because it can indicate early stages of dysphagia.
Clients with dysphagia typically have orders for thickened liquids. Thickened liquids are easier for the epiglottis to prevent from entering the lungs. Here are common types of liquid consistencies
ordered:
Regular or Thin Liquids: No modifications for liquid consistency are required.
Nectar Thick (NT): Fluids are modified to have the consistency of thicker juices like a creamy soup.
Honey Thick (HT): Fluids are modified to have the consistency of honey or syrup that pour very slowly and may be consumed with a spoon.
Pudding Thick (PT): Fluids are modified to have semi-solid consistency like pudding. A spoon stands up in pudding-thick liquid.
[19]
See Figure 6.5 for an illustration comparing liquid consistency.

Figure 6.5 Liquid Consistencies for Regular (Thin), Honey Thick, and Pudding-Thick Liquids
[20]
Liquids can be thickened using thickening powder. Pre-thickened liquids from manufacturers typically have a smoother consistency than prepared liquids. See Figure 6.6 for an image of a
commercial thickening powder in use. Thickening liquid with powder requires exact attention to measurements to ensure the resident receives the correct liquid consistency and does not aspirate the
[21]
fluid. Ice cubes should not be added to thickened liquids because as they melt, the liquid will become thinner. See Figure 6.7 for an image of thickening water.

Figure 6.6 Pre-thickened Water

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 Figure 6.7 Thickened Water

Read additional information on modified diets and liquid consistencies in the Virginia Department of Behavioral Health and Developmental Services PDF.

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
8. MyPlate.gov. (n.d.). What is MyPlate? U.S. Department of Agriculture. https://www.myplate.gov/eat-healthy/what-is-myplate ↵
9. “MyPlate_blue.png” by USDA is licensed under CC0 ↵
10. This image is a derivative of “Table 3.1 Water Content in Foods” by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed under CC BY-NC-SA 4.0 ↵
11. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 ↵
12. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 ↵
13. “Regulating-Water-intake-.jpg” by Allison Calabrese is licensed under CC BY 4.0. Access for free at https://pressbooks.oer.hawaii.edu/humannutrition/chapter/regulation-of-water-balance/ ↵
14. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 ↵
15. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 ↵
16. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
17. “dysphagia-meat-and-potatoes-1w03r35.jpg” by Savannah Greiner is used with permission. Access for free at https://sites.udel.edu/chs-udfoodlab/2017/04/10/learning-about-dysphagia/ ↵
18. “dysphagia-pureed-breakfast-1kl60uo.jpg” by Savannah Greiner is used with permission. Access for free at https://sites.udel.edu/chs-udfoodlab/2017/04/10/learning-about-dysphagia/ ↵
19. “Honey Thick Liquid,” “Pudding Thick,” and “Thin Liquid” by Open RN Project are licensed under CC BY 4.0 ↵
20. “Powdered Thickener" and "Adding Thickener to Water" by Landon Cerny are licensed under CC BY 4.0↵
21. “Thickened Water” by Landon Cerny is licensed under CC BY 4.0 ↵

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the LibreTexts platform; a detailed edit history is available upon request.

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6.3: Pain
Pain is traditionally defined in health care as, “Whatever the patient says it is, experienced whenever they say they are
[1]
experiencing it.” In 2020 the International Association for the Study of Pain released a revised definition of pain as, “An
unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue
damage,” along with these additional notes:
Pain is always a personal experience that is influenced to varying degrees by the body’s ability to function, how the brain
perceives pain, and even how pain has been reacted to or cared for by others in the past.
Individuals learn the concept of pain throughout all stages of their life.
A person’s report of an experience of pain should be respected.
Although pain usually serves an adaptive role to protect oneself, it can have adverse effects on function, socialization, and
psychological well-being.
Verbal description is only one of several behaviors that express pain. The inability to communicate does not negate the
[2]
possibility that a person is experiencing pain.
Be aware that cultural beliefs and generational norms affect how an individual expresses their pain.
Pain motivates the individual to withdraw from dangerous stimuli, like touching a hot stove. It reminds the body to protect an
injured part while it heals, such as not walking on a sprained ankle. Most pain resolves after the painful stimulus is removed and
the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body. Pain can also
[3] [4]
occur in the absence of any detectable stimulus, damage, or disease. ,

Factors Affecting Pain

There are many factors that affect how a person perceives pain, how they will act while they are in pain, and how they
[5]
communicate their pain to others. See Table 6.3a for common factors that influence pain.
[6]
Table 6.3a Factors Affecting Pain

Biological Factors Psychological Factors Social Factors

Nociception Mood/affect Culture

Brain function Fatigue Values
Source of pain Stress Economic
Illness Coping Environment
Medical diagnosis Trauma Social support
Age Sleep Coping mechanisms
Injury, past or present Fear Spirituality
Genetic sensitivity Anxiety Ethnicity
Hormones Developmental stage Education
Inflammation Meaning of pain
Obesity Memory
Cognitive function Attitude
Beliefs
Emotional status
Expectations

There are endless sources of pain. For example, as people age, osteoarthritis is a common cause of pain. Osteoarthritis is a type of
arthritis causing inflammation or swelling of the joints due to daily wear and tear on the body. The extent of a person’s arthritis can
be affected by repeatedly performing physically demanding tasks such as those found in jobs such as health care, construction, and
manufacturing. Topical medications and treatments such as arthritis cream, ice, or heat can be very effective in managing arthritis
pain.

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Acute Versus Chronic Pain
The duration of a person’s pain can be classified as either acute or chronic. Acute pain has limited duration and is associated with a
specific cause. It is often attributed to a specific event, such as a fracture, childbirth, or surgery, and should lessen as the body heals.
Acute pain usually causes observable physiological responses such as increased pulse, respirations, and blood pressure. The person
[7]
may also have excessive sweating called diaphoresis.
Chronic pain is ongoing and persistent for longer than six months. It typically does not cause a change in vital signs or
diaphoresis. Chronic pain can affect an individual’s psychological, social, and behavioral responses and impact daily functioning.
Chronic medical problems, such as osteoarthritis, spinal conditions, fibromyalgia, and peripheral neuropathy, are common causes
of chronic pain. Chronic pain can continue even after the original injury or illness that caused it has healed or resolved. Some
people suffer chronic pain even when there is no past injury or apparent body damage, and it may not be located in a specific area
[8]
of the body.
People experiencing chronic pain often have other physical effects that are stressful on the body such as tense muscles, limited
ability to move around, lack of energy, and appetite or sleep changes. Emotional effects of chronic pain include depression, anger,
[9] [10]
anxiety, and fear of reinjury. These effects can limit a person’s ability to return to their regular work or leisure activities. ,

Objective and Subjective Signs of Pain

The concepts of objective and subjective data were previously discussed in the Chapter 1, “Guidelines for Reporting” subsection.
Subjective signs of pain are what the person reports to you, such as “My stomach hurts” or “My knees ache when I walk.”
Objective data is observable, such as the change in vital signs that can occur when an individual is experiencing acute pain. Signs
of pain can also include nonverbal responses such as grimacing, guarding the injured body part, rocking, rubbing the area, or
[11]
moaning. See Figure 6.8 for an image of observable signs of pain.

Figure 6.8 Observable Signs of Pain

When an individual is unable to communicate pain due to cognitive deficits, recognizing objective signs of pain is vital for
providing comfort measures and improving their quality of life. The Pain Assessment in Advanced Dementia (PAINAD) is an
[12]
example of a tool that nurses and NAs use to identify the presence of pain in individuals who are unable to verbally report it. See
the PAINAD scale in Table 6.3b. A number is identified for each row and the total number is their pain rating.
[13]
Table 6.3b PAINAD Scale

Item 0 1 2

Noisy labored breathing. Long

Breathing independent of Occasional labored breathing.
Normal period of hyperventilation.
vocalization Short period of hyperventilation.
Cheyne-Stokes respirations.

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 Occasional moan or groan. Low-
Repeated trouble calling out. Loud
Negative vocalization None level speech with a negative or
moaning or groaning. Crying.
disapproving quality.

Facial Expression Smiling or inexpressive Sad. Frightened. Frowning. Facial grimacing.

Rigid. Fists clenched. Knees

Tense. Distressed pacing.
Body language Relaxed pulled up. Pulling or pushing
Fidgeting.
away. Striking out.

Distracted or reassured by voice Unable to console, distract, or

Consoling No need to console
or touch. reassure.

1. Pasero, C., & MacCaffery, M. (2010). Pain assessment and pharmacological management (1st ed.). Mosby. ↵
2. International Association for the Study of Pain. (2017, December 14). Terminology. https://www.iasp-
pain.org/Education/Content.aspx?ItemNumber=1698 ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 ↵
5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
6. Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department
of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf ↵
7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
10. Cleveland Clinic. (2020, December 8). Acute vs. chronic pain. https://my.clevelandclinic.org/health/articles/12051-acute-vs-
chronic-pain ↵
11. “238074231_2485ed053b_o” by Erik Ogan is licensed under CC BY-SA 2.0 ↵
12. Warden, V., Hurley, A., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced
dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4(1), 9-15.
https://doi.org/10.1097/01.JAM.0000043422.31640.F7 ↵
13. Warden, V., Hurley, A., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced
dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4(1), 9-15.
https://doi.org/10.1097/01.JAM.0000043422.31640.F7 ↵

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6.4: Comfort Measures
Nursing assistants (NAs) should report subjective and objective signs of clients’ pain to the nurse for further assessment. After
assessing the client, the nurse may choose to administer medication with provider order and/or provide other nonpharmacological
treatments. The nurse may delegate tasks to the NA such as the application of over-the-counter topical medications, ice, or heat.
The NA may also assist with repositioning and massage.

Topical Medications
Topical medications are applied to the skin and are typically over-the-counter (OTC) medications, meaning no prescription is
needed to obtain them. Topical analgesics may come as a cream, gel, spray, or patch. An example of a topical analgesic is “Icy-
Hot” cream.
There are also other types of topical medications an NA may be delegated to apply, such as antifungal medications (e.g., Nystatin
in powder or cream form) or barrier creams to reduce the risk of skin breakdown or assist in healing of opened areas. When
applying topical medications, it is important to use diligent infection control measures to prevent the medication from becoming
contaminated. See the “Topical Medications” Skills Checklist for steps on how to properly apply topical medications.

Ice and Heat Applications

Applying ice and heat can also be delegated from the registered nurse to the NA. To safely apply ice or heat, first place a thin
barrier on the skin, such as a towel or washcloth, to avoid damaging the tissue. Ice may be placed in a plastic bag, or cold therapy
may be available in a disposable package. In some situations, a reusable gel pack may be placed in the freezer between uses.
Heat applications may include using an electrical heating pad or a reusable microwavable pack. The NA should discuss the setting
for the heating pad or the time the pack should be warmed in the microwave with the delegating nurse. The NA should feel the
pack’s temperature before placing it on the resident.
Ice or heat applications are typically left on for 15-20 minutes. If the resident is unable to communicate, the NA should lift the
pack, check the skin temperature, and look for any redness every five minutes to prevent damage to the skin. If the ice or heat
applications are not disposable, ensure they are sanitized according to agency policy before providing them to the resident.

Positioning and Massage

Pain may arise when a client remains in one position too long or is placed in a position that causes pressure on a sensitive area such
as a joint, tendon, or muscle. Residents who are unable to move on their own should be repositioned at least every two hours, and
some may require more frequent repositioning due to pain or skin issues. Clients can be maintained in a position of comfort by
placing pillows to prevent discomfort between joints and bony prominences or to support the body and prevent them from rolling
out of the position. For information on proper positioning, see Chapter 8.
Massage provides relaxation by reducing soreness and tension in muscles. It also increases circulation by promoting blood flow.
However, a massage should never be provided over red or swollen areas. A massage given to a resident for pain relief should last
about 3-5 minutes. For specifics on giving a massage, see the 5.17 “Back Rub” Skills Checklist in Chapter 5.

Other Comfort Measures

In addition to the previously described interventions to reduce pain, NAs can further help reduce clients’ pain by offering
distractions, such as talking with the resident about pleasant or interesting things that the resident enjoys, looking at photos or
magazines, playing board games, or listening to music. Deep breathing, mindfulness techniques, aromatherapy, and light range of
motion (ROM) activities can also help calm the resident and ease their pain. Read more about providing ROM activities in Chapter
[1]
9. See Figure 6.9 for images of nonpharmacological treatments for pain.

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 Figure 6.9 Nonpharmacological Treatments for Pain

Read more about pain management for older adults from the University of Iowa.

1. “Massage-hand-4.jpg” by Lubyanka is licensed under CC BY-SA 3.0, “Biofeedback_training_program_for_post-

traumatic_stress_symptoms.jpg” by Army Medicine is licensed under CC BY 2.0, “Tai_Chi1.jpg” by Craig Nagy is licensed
under CC BY-SA 2.0, “Musicoterapia_lmidiman_flickr.jpg” by Midiman is licensed under CC BY 2.0, “Cold_Hot_Pack.jpg”
by Mamun2a is licensed under CC BY-SA 4.0, “pexels-photo-1188511.jpeg” by Mareefe is licensed under CC0, “STOTT-
PILATES-reformer-class.jpg” by MHandF is licensed under CC BY-SA 3.0, “prayer-2544994_960_720.jpg” by Himsan is
licensed under CC0, and “gaming-2259191_960_720.jpg” by JESHOOTS-com is licensed under CC0↵

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6.5: Effects of Prescribed Routine Medications
NAs may not be aware of all the medications a client is receiving, but the nurse should inform the NA of potential harmful side
effects to report when a new medication has been prescribed. The NA should be vigilant for possible side effects, especially if it is
known that a new medication has been prescribed. Common side effects to report to the nurse are as follows:
Dizziness
Drowsiness
Change in cognition (i.e., new confusion)
Constipation; diarrhea; or dark, bloody or tarry stools
Nausea or vomiting
Dry mouth
Ringing in the ears
Itchy skin or rash
Increased urination or discolored urine
Muscle aches
Bleeding gums
Increased bruising

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6.6: End-of-Life Care
There are many circumstances and medical diagnoses that may cause an individual to approach the end of their life. The natural aging
process and chronic conditions such as heart failure (HF), chronic obstructive pulmonary disease (COPD), cancer, and advanced dementia
may lead to end-of-life care.
All nursing care should be provided in a holistic, person-centered approach, but during end-of-life care, all caregivers must be fully attuned
to the needs and wishes of the person. Caregivers often have a long-standing relationship with the dying person, but it is critical to not
assume their client’s preferences. Communication must be more frequent and intentional during end-of-life care because a patient’s needs
can change quickly. Additionally, attitudes and mental outlooks often fluctuate for the patient and their loved ones during this difficult time
when many decisions need to be made. It is essential for caregivers to find an appropriate balance of interventions and space for the dying
person and their loved ones. Use techniques discussed in Chapter 1 for therapeutic communication and making observations of facial
expressions and body language to guide your interactions with the resident and their loved ones.
As discussed in Chapter 2.6, “Health Care Settings,” hospice care is a choice offered to individuals approaching end of life. Hospice care is
offered to patients who are terminally ill and expected to live less than six months. Hospice provides comfort to the client and supports the
family, but curative medical treatments are stopped. It is based on the idea that dying is part of the normal life cycle. Hospice care does not
[1]
hasten death but focuses on providing comfort. For example, a cancer patient may choose to no longer receive chemotherapy due to its
severe side effects but will continue to take medications to manage pain and nausea. While nutritional intake is still important, food choices
center around those that are pleasurable to the client rather than meeting their daily requirement of nutrients.
Hospice is a service provided by Medicare and can be delivered in a person’s home or in a facility such as a nursing home or hospital. To
qualify for hospice care, a hospice doctor and the client’s primary doctor must certify that the person is terminally ill with a life expectancy
of six months or less. The client signs a statement choosing hospice care instead of curative care covered by Medicare. Hospice coverage
includes the following:
All items and services needed for pain relief and symptom management
Medical, nursing, and social services
Medications for pain management
Durable medical equipment for pain relief and symptom management
Aide and homemaker services
Physical therapy services
Occupational therapy services
Speech-language pathology services
Social services
Dietary counseling
Spiritual and grief counseling for the client and their family
Short-term inpatient care for pain and symptom management in a Medicare‑approved facility, such as a hospice facility, hospital, or
skilled nursing facility that contracts with the hospice agency
Inpatient respite care, which is care provided in a Medicare-approved facility so the usual caregiver (like a family member or friend) can
rest. The client can stay up to five days each time respite care is needed. Respite care can occur more than once but only on an
occasional basis.
Other services that Medicare covers to manage pain and other symptoms related to the terminal illness and related conditions the
[2]
hospice team recommends
After two physicians agree that a person qualifies for hospice, a nurse from a hospice agency completes an assessment and makes care
recommendations. If the client is in a nursing home, their hospice team will coordinate with the facility team to manage the client’s needs
and wishes. Visits are scheduled at intervals designated by the hospice team. A hospice nursing assistant may come to the facility to provide
cares because they can spend more time with the enrolled hospice client than routinely provided by the facility staff. This extra time can
reduce pain that may occur during cares by moving at a slower pace and allowing for periods of rest. The additional social interaction is
also beneficial for the hospice client. To improve quality of life, hospice may also provide additional resources such as spiritual chaplains,
music therapists, or volunteers who simply visit with the client if they do not have friends or family available.
If a hospice client remains in their own home, the hospice agency provides durable medical equipment like a hospital bed and other items to
make caring for the client easier, such as a commode, shower chair, or mechanical lift for moving the client. The hospice nurse and nursing
assistant visit regularly based on the needs of the client and their family. The nurse’s or nursing assistant’s visits may also serve as respite,
allowing the loved ones a reprieve from caring for the client themselves.
Nursing assistants may choose to work for a hospice agency and receive additional training to better understand and provide end-of-life
care.

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Ethical and Legal Considerations
End-of-life care often includes unique complexities for the patient, family, and nurse. There may be times when what the physician or nurse
believes to be the best treatment conflicts with what the patient or family desires. There may also be challenges related to decision-making
that cause disagreements within a family or cause conflict with the treatment plan. Additional challenging factors during end-of-life care
[3]
include availability of resources and insurance company policies.
Despite these complexities, it is important for the care team to honor and respect the wishes of the patient. Despite any conflicts in
decision-making among health care providers, family members, and the patient, the team must always advocate for the patient’s wishes. If a
nursing assistant notices conflicts or is questioned by the client or family members, they should notify the nurse. Nurses have practice
guidelines for ethical dilemmas in the American Nurses Association’s Standards of Professional Nursing Practice and Code of Ethics.
[4]
These resources assist the nurse in implementing expected behaviors according to their professional role as a nurse.
If complex ethical dilemmas occur, many organizations have dedicated ethics committees that offer support, guidance, and resources for
complex ethical decisions. These committees can serve as support systems, share resources, provide legal insight, and make
recommendations for action. The nursing assistant should always include their supervisor in any questionable situation and feel supported
[5]
in raising concerns within their health care organization if they believe an ethical dilemma is occurring.

Do-Not-Resuscitate Orders and Advanced Directives

Additional legal considerations when providing care at the end of life are do-not-resuscitate (DNR) orders and advance directives.

Do-Not-Resuscitate Orders
A Do-Not-Resuscitate (DNR) order is a medical order that instructs health care professionals to not perform cardiopulmonary
resuscitation (CPR) if a patient’s breathing stops or their heart stops beating. CPR is emergency treatment provided when a patient’s blood
flow or breathing stops and may involve chest compressions and mouth-to-mouth breathing, electric shocks to restart the heart, breathing
tubes to open the airway, or cardiac medications.
A DNR order is written with permission by the patient (or the patient’s health care power of attorney, if activated). Ideally, a DNR order is
set up before a critical condition occurs. A DNR order is recorded in a patient’s medical record and only refers to not performing CPR and
does not affect other care. Wallet cards, bracelets, or other DNR documents are also available for individuals to have at home or in
nonhospital settings.
The decision to implement a DNR order is typically very difficult for a patient and their family members to make. Many people have
unrealistic ideas regarding the success rates of CPR and the quality of life a patient experiences after being revived, especially for patients
with multiple chronic diseases. For example, a recent study found the overall rate of survival leading to hospital discharge for someone who
[6]
experiences cardiac arrest is about 10.6 percent.
Nurses can provide up-to-date patient education regarding CPR and its effectiveness based on the patient’s current condition and facilitate
discussion about a DNR order. Nursing assistants can provide CPR based on their scope of practice within their state. If a nursing assistant
[7]
witnesses a cardiac event, their first action should be to notify the nurse.

Advance Directives
Advance directives include the health care power of attorney (POA) and living will. The health care POA legally identifies a trusted
individual to serve as a decision-maker for health issues when the patient is no longer able to speak for themselves. It is the responsibility
of this designated individual to carry out care actions in accordance with the patient’s wishes. A health care POA can be a trusted family
member, friend, or colleague who is of sound mind and is over the age of 18. They should be someone who the patient is comfortable
[8]
expressing their wishes to and someone who will enact those desired wishes on the patient’s behalf.
The health care POA should also have knowledge of the patient’s wishes outlined in their living will. A living will is a legal document that
describes the patient’s wishes if they are no longer able to speak for themselves due to injury, illness, or a persistent vegetative state. The
living will addresses issues like ventilator support, feeding tube placement, cardiopulmonary resuscitation, and intubation. It is a vital
means of ensuring that the health care provider has a record of one’s wishes. However, the living will cannot feasibly cover every possible
[9]
potential circumstance, so a health care power of attorney is vital when making decisions outside the scope of the living will document.
A financial power of attorney may also be appointed to manage the client’s money matters when they are no longer able to do so. The
financial POA can be the same person as the health care POA or a different individual. The financial POA may be enacted independently of
the health care POA, meaning that the client can still make their own health care decisions even if their finances are controlled by their
designee. The client should select both POAs when they are still able to make sound decisions. Two physician signatures are required to
enact each POA to avoid a conflict of interest and ensure the client truly cannot make appropriate decisions. If a client has not filed these
[10]
legal documents and is deemed incompetent, a state guardian will be appointed as their financial and health care POA.

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Signs of Impending Death
As a person nears dying there are several notable physiological changes, especially with circulation, breathing, intake, and appearance of
skin. The heart rate will slow and blood pressure lowers, creating cool extremities that may appear cyanotic (blue), pale, or dark.
Respirations may become very irregular, referred to as Cheyne-Stokes breathing. Cheyne-Stokes respirations can be observed as gaps in
breathing of several seconds, and long and labored or quick and shallow inhalation and exhalation. There may be gurgling or rattling of the
lungs when breathing. Intake will decrease and eventually stop altogether, and output will follow the same pattern. Mottling, which looks
like severely wrinkled and purple-bluish color skin, often occurs in dependent areas or lower legs and feet.
At some point, the dying person becomes unresponsive, which often leads to the jaw opening. Although the dying person may no longer
communicate, hearing is the last sense to fail. It is critical that caregivers continue to talk to the dying person as if they were alert and able
to understand.

Care for the Dying Person

Because the end of life is a very emotional time, the person needs to be supported and involved in their care as much as possible to
maintain their sense of control. Interventions should center on quality of life and comfort measures. Another important aspect is including
loved ones. Their level of involvement should be discussed with the client at an appropriate time when they are able to communicate and
understand the conversation. In a long-term care facility, the care team has this conversation with the resident, and it is implemented into
the care plan for the nursing assistant to carry out.
Attention to pain is very important. Notify the nurse 10-15 minutes before you plan on providing care so they can assess the resident’s pain
and determine if pain medication is needed prior to assisting the resident.
Repositioning should occur hourly due to decreased circulation and a high risk for skin breakdown. Incontinence care and all other hygiene
should be completed in bed, and their skin should continue to be moisturized. Massage can help with circulation if it is tolerated by the
resident. Due to the jaw opening and breathing with the mouth open, oral care using a moist swab should be done hourly. Consider applying
lip balm or other moisturizer at the same time.
The room should be quiet, and lighting should be lowered to the resident’s comfort level. Scents from flowers, deodorizer, or perfumes may
be more irritating than normal and should be avoided. Visiting times, as well as the amount of people in the room, may be determined by
the nurse. A private area with refreshments away from the resident room should be available for loved ones to gather and rest as needed.
Be aware that hearing is the last sense to go. Explain to the patient what you are doing before you do it and be conscientious of the words
being used near the patient. Encourage family members and staff members to talk to the patient even if they are not responding; talking can
be comforting to the patient, family members, and caregivers.

Stages of Grief
There are several stages of grief that may occur due to any major life change, including end of life and death. It is helpful for caregivers to
have an understanding of these stages so they can recognize the emotional reactions as symptoms of grief and support patients and families
as they cope with loss. Famed Swiss psychiatrist Elizabeth Kubler-Ross identified five main stages of grief in her book On Death and
Dying. Patients and families may experience these stages along a continuum, move randomly and repeatedly from stage to stage, or skip
stages altogether. There is no one correct way to grieve, and an individual’s specific needs and feelings must remain central to care
[11]
planning.
Kuber-Ross identified that patients and families demonstrate various characteristic responses to grief and loss. These stages include denial,
[12]
anger, bargaining, depression, and acceptance, commonly referred to by the mnemonic “DABDA.” See Figure 6.10 for an illustration of
the Kubler-Ross Grief Cycle. Keep in mind that these stages of grief not only occur due to loss of life, but also due to significant life
changes such as divorce, loss of friendships, loss of a job, or diagnosis with a chronic or terminal illness.[13]

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 Figure 6.10 Kubler-Ross Grief Cycle

Denial
Denial occurs when the individual refuses to acknowledge the loss or pretends it isn’t happening. This stage is characterized by an
individual stating, “This can’t be happening.” The feeling of denial is self-protective as an individual attempts to numb overwhelming
emotions as they process the information. The denial process can help to offset the immediate shock of a loss. Denial is commonly
experienced during traumatic or sudden loss or if unexpected life-changing information or events occur. For example, a patient who
presents to the physician for a severe headache and receives a diagnosis of terminal brain cancer may experience feelings of denial and
[14]
disregard the diagnosis altogether. See Figure 6.11 for an image of a person reacting to unexpected news with denial.

Figure 6.11 Denial

Anger
Anger in the grief process often masks pain and sadness. The subject of anger can be quite variable; anger can be directed to the individual
who was lost, internalized to self, or projected toward others. Additionally, an individual may lash out at those uninvolved with the
situation or have bursts of anger that seemingly have no apparent cause. As a nursing assistant, you may possibly be the target of someone’s
projected anger. Health care professionals should be aware that anger may often be directed at them as they provide information or provide
care. It is important that health care team members, family members, and others who become the target of anger seek to recognize that the
anger and emotion are not a personal attack, but rather a manifestation of the challenging emotions that are a part of the grief process. It
often comes from a loss of control in the situation and a feeling of helplessness or hopelessness. If possible, the nursing assistant can
provide supportive presence and allow the patient or family member time to vent their anger and frustration while still maintaining
boundaries for respectful discussion. Rather than focusing on what to say or not to say, allowing a safe place for a patient or family member
[15]
to verbalize their frustration, sorrow, and anger can offer great support. See Figure 6.12 for an image of a patient experiencing anger.

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 Figure 6.12 Anger

Bargaining
Bargaining can occur during the grief process in an attempt to regain control of the loss. When individuals enter this phase, they are looking
to find ways to change or negotiate the outcome by making a deal. Some may try to make a deal with God or their higher power to take
away their pain or to change their reality by making promises to do better or give more of themselves if only the circumstances were
different. For example, a patient might say, “I promised God I would stop smoking if He would heal my wife’s lung cancer,” or “I’ll go to
church every week if I can be healthy again.” There may also be thoughts such as “Why isn’t this happening to me instead of my child?”

Depression
Feelings of depression can occur with intense sadness over the loss of a loved one or the situation. Depression can cause loss of interest in
activities, people, or relationships that previously brought one satisfaction. There is no pleasure or joy surrounding anything. Additionally,
individuals experiencing depression may experience irritability, sleeplessness, and loss of focus. It is not uncommon for individuals in the
depression phase to experience significant fatigue and loss of energy. Simple tasks such as getting out of bed, taking a shower, or preparing
a meal can feel so overwhelming that individuals simply withdraw from activity. In the depression phase, it can be difficult for individuals
to find meaning, and they may struggle with identifying their own sense of personal worth or contribution. Depression can be associated
with ineffective coping behaviors, and nursing assistants should watch for signs of self-medicating through the use of alcohol or drugs to
mask or numb depressive feelings. Any remarks made about feeling depressed or talk of self-harm should be reported immediately. Other
symptoms to report include noticed changes in behavior such as isolation or withdrawal from activity, sleeping more or less, and decreased
[16]
interest in hygiene and self-care. Further discussion about depression can be found in Chapter 10. See Figure 6.13 for an image of an
individual demonstrating feelings of depression.

Figure 6.13 Depression

Acceptance
Acceptance refers to an individual understanding the loss and knowing it will be hard but acknowledging the new reality. The acceptance
phase does not mean absence of sadness but is the acknowledgement of one’s capabilities in coping with the grief experience. In the
acceptance phase, individuals begin to re-engage with others, find comfort in new routines, and even experience happiness with life
activities again. This may be observed by a person saying, “I want to make the most of the time I have left by spending it with my family”
or “I’d like to plan the arrangements for my funeral” or “I know this will be painful and difficult, but I will be okay with the supports I
[17]
have.” See Figure 6.14 of an image representing an individual who has reached acceptance of the new reality related to his loss.

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 Figure 6.14 Acceptance

Assisting in the Grieving Process

As already discussed, the grieving process is different for each individual and is not easily predicted. The best action for the caregiver is to
listen closely and offer support to the individual. Other possible interventions for the NA to assist with the grieving process are described in
Table 6.6.
Table 6.6 Suggested Actions by the Nursing Assistant According to the Client’s Stage of Grief

Stage of Grief Suggested Actions by the Nursing Assistant

Offer support and give the person time to sort through feelings.
Denial Do not respond with messages such as “You will get over this” or
“Everything will be fine eventually.”

Explain cares provided and refer to the nurse if needed.

Listen to the client and/or their loved ones without judgment or offering
Anger opinions.
Involve the client in choices regarding their cares as appropriate to give
them a sense of control.

Bargaining Assist in contacting a spiritual or religious counselor.

Offer activities the client previously enjoyed.

Depression Encourage participation in ADLs.
Report behavioral changes to the nurse.

Validate thoughts and any plans made.

Acceptance
Focus on quality of life.

If the dying client lives in a facility, it is important to consider how their death may affect other residents, as well as the staff members.
Some facilities may offer grief counseling that includes sharing thoughts, feelings, or memories of the deceased in a group or individual
setting. A memorial service may be held at the facility for residents and staff separate from the family’s plans. Staff and residents will also
work through the grieving process, so offering the same interventions as listed above is warranted. Additionally, it is good to promote self-
care by maintaining adequate nutritional intake and sleep.

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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 2. Ouellette, L., Puro, A., Weatherhead, J., Shaheen, M., Chassee, T., Whalen, D., & Jones, J. (2018). Public knowledge and perceptions
about cardiopulmonary resuscitation (CPR): Results of a multicenter survey. The American Journal of Emergency Medicine, 36(10),
1900-1901. https://doi.org/10.1016/j.ajem.2018.01.103 ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
10. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
11. This work is a derivative of Nursing Care at the End of Life by Lowey and is licensed under CC BY-NC-SA 4.0 ↵
12. “Kubler-ross-grief-cycle-1-728.jpg” by U3173699 is licensed under CC BY-SA 4.0↵
13. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
14. “Young-indian-with-disgusting-expression-showing-denial-with-hands-42509-pixahive.jpg” by Sukhjinder is licensed under CC0↵
15. “Child's_Angry_Face.jpg” by Babyaimeesmom is licensed under CC BY-SA 4.0↵
16. “Depressed_(4649749639).jpg” by Sander van der Wel is licensed under CC BY-SA 2.0↵
17. “Contentment_at_its_best.jpg” by Neha Bhamburdekar is licensed under CC BY-SA 4.0↵

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6.7: Postmortem Care
The nurse will determine when an individual has died and follow agency policies. If loved ones are present, allow them to stay with
the person’s body as long as needed for them to say goodbye. If they express any religious or cultural preferences, they should be
accommodated as much as possible. For example, individuals from some cultures prefer to cleanse their loved one’s body after
death. When sufficient time has been granted, the nursing assistant will prepare the body for transport.
When postmortem care is provided, it is appropriate to ask the family to leave the room. You will provide a bed bath to the resident
and then position them in correct alignment. A new gown should be placed on the resident. Because urine or feces is often expelled
when the resident is moved for transport, a clean incontinence brief should be provided after the bath is completed. The resident’s
eyelids and mouth should be gently closed if they are still open. A rolled towel can be placed under the chin to stabilize the jaw.
Cover the resident to the neck with clean linens, leaving the face and head uncovered. Check facility policy for applying an
identification bracelet.
The postmortem care process can be very difficult for a new nursing assistant or whenever it is completed the first few times. Be
sure to ask for assistance from a more experienced nursing assistant or the nurse or consider completing the postmortem cares with
another staff member to ease the difficulty of the experience.

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6.8: Skills Checklist- Topical Medications
1. Gather Supplies: Topical medication, gloves, medicine cup, medicine spoon (if medication is in a jar), and barrier
2. Routine Pre-Procedure Steps:
Knock on the resident’s door.
Perform hand hygiene.
Maintain respectful, courteous, and professional communication at all times.
Introduce yourself and identify the resident.
Provide for privacy.
Explain the procedure to the resident.
3. Procedure Steps:
Put on gloves.
Place the appropriate amount of medication from the tube, jar, or bottle in a medicine cup. If the medication is in a jar, use a
medication spoon to scoop out the medication. Do not put your hands directly into the jar. If using a tube, do not squeeze the
medication onto your gloved hand.
Place the medication on a flat surface with a barrier.
Clean the area where the medication is to be applied. If there is a patch, confirm with the nurse that it should be removed.
Remove gloves, turning them inside out.
Perform hand hygiene.
Put on clean gloves.
Using your gloved hand, apply medication from the cup onto the affected area. Be sure to gently rub in the medication so it
can be absorbed by the skin for maximum effectiveness.
Remove gloves, turning them inside out.
4. Post-Procedure Steps:
Perform hand hygiene.
Check the resident’s comfort and if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and the privacy curtain.
Perform hand hygiene.
Document and report any skin issues or changes to the nurse.
View a YouTube video[1] of an instructor demonstration of topical medications:

Topical Medications

1. Chippewa Valley Technical College. (2022, December 3). Topical Medications. [Video]. YouTube. Video licensed under CC
BY 4.0. https://youtu.be/ZJGNFg6ccYM ↵

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6.9: Learning Activities

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6.10: VI Glossary
Acute pain: Pain with limited duration and associated with a specific cause. It usually causes observable responses such as
increased pulse, respirations, and blood pressure. The person may also have diaphoresis.
Advance directives: Legal documents including the health care power of attorney (POA) and living will.
Cardiopulmonary resuscitation (CPR): Emergency treatment provided when a patient’s blood flow or breathing stops and may
involve chest compressions and mouth-to-mouth breathing, electric shocks to restart the heart, breathing tubes to open the airway,
or cardiac medications.
Cheyne-Stokes: Irregular respirations associated with approaching death that are observed as gaps in breathing of several seconds
and long and labored or quick and shallow inhalation and exhalation.
Chronic pain: Ongoing and persistent pain for longer than six months. It typically does not cause a change in vital signs or
diaphoresis.
Cyanotic: A bluish discoloration of the skin.
Diaphoresis: Excessive sweating.
Do-Not-Resuscitate (DNR) order: A medical order that instructs health care professionals to not perform cardiopulmonary
resuscitation (CPR) if a patient’s breathing stops or their heart stops beating. A DNR order is only written with permission by the
patient (or the patient’s health care power of attorney, if activated).
Dysphagia: Difficulty swallowing that can cause aspiration of liquids and food into one’s lungs and lead to life-threatening
pneumonia.
End-of-life care: Term used to describe care provided when death is imminent and life expectancy is limited to a short number of
hours or days.
Epiglottis: The anatomical flap that covers the trachea and prevents liquids from entering the lungs when swallowing.
Health Care Power of Attorney (POA): Legal identification of a trusted individual to serve as a decision-maker for health issues
when the patient is no longer able to speak for themselves. It is the responsibility of this designated individual to carry out care
actions in accordance with the patient’s wishes.
Hospice care: Care provided to patients who are terminally ill when a health care provider has determined they are expected to live
six months or less. Hospice provides comfort to the client and supports the family, but curative medical treatments are stopped. It is
based on the idea that dying is part of the normal life cycle.
Living will: A legal document that describes the patient’s wishes if they are no longer able to speak for themselves due to injury,
illness, or a persistent vegetative state. The living will addresses issues like ventilator support, feeding tube placement,
cardiopulmonary resuscitation, and intubation.
Macronutrients: Carbohydrates, proteins, and fats that make up most of a person’s diet and provide energy, as well as essential
nutrient intake.
Modified diet: Any diet altered to include or exclude certain components. For example, a low-salt diet is an example of a modified
diet.
NPO: A common medical abbreviation referring to “nothing by mouth.”
Osteoarthritis: A type of arthritis causing inflammation or swelling of the joints due to daily wear and tear on the body.
Pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential
tissue damage.
Postmortem care: Care provided after death has occurred through transfer to a morgue or funeral provider.
Quality of life: The degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events.

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 CHAPTER OVERVIEW

7: Demonstrate Reporting and Documentation of Client Data

7.1: Introduction to Demonstrate Reporting and Documentation of Client Data
7.2: Documenting and Reporting Data
7.3: Recognizing Signs of Client Discomfort
7.4: Obtaining Vital Signs
7.5: Normal Ranges for Vital Signs
7.6: Measuring Weight and Height
7.7: Measuring Intake and Output
7.8: Skills Checklist- Oral, Tympanic, Axillary, Rectal and Temporal Temperatures
7.9: Skills Checklist- Pulse
7.10: Skills Checklist- Respirations
7.11: Skills Checklist- Measuring Height for Ambulatory Residents
7.12: Skills Checklist- Measuring Weight for Ambulatory Residents
7.13: Learning Activities
7.14: VII Glossary

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1
7.1: Introduction to Demonstrate Reporting and Documentation of Client Data
Learning Objectives
Measure temperature, pulse, and respiration
Measure weight and height
Recognize normal and abnormal blood pressure readings
Identify normal and abnormal vital signs
Measure intake and output
Document client data
Prioritize the reporting of data
Recognize signs of client discomfort

Nursing assistants collect and document client data such as vital signs, height, weight, intake, and output. While performing cares
and collecting data, nursing assistants spend a lot of time with residents and may observe subtle changes in behavior, mood,
mobility, and cognition, as well as signs of discomfort. They report these observations promptly to nurses to ensure safe, quality,
holistic care. This chapter will discuss collection of this data, as well as prioritization of data that should be immediately reported to
the nurse.

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7.2: Documenting and Reporting Data
Documentation is legally required for nursing assistants and other health care team members to record client observations and care
provided in the medical record. Documentation is used to ensure continuity of care across shifts and among health care team
members, to monitor standards of care for quality assurance activities, and to provide information for reimbursement purposes by
insurance companies and Medicare or Medicaid. Documentation may also be used for research purposes or, in some instances, for
[1]
legal concerns in a court of law. For these reasons, always document the care you provide and never document for someone else.
Review Chapter 1, “Documenting and Reporting” for details on how observations should be recorded. The facility or employer
should provide training on how to document according to their expectations and what should be included in the client’s record.
Charting by exception (CBE) is a common type of health care documentation indicating routine care and collection of data were
completed. Notes are only written for abnormal findings or anything out of the ordinary. CBE is designed to keep documentation
concise and reduce the amount of time required for documentation. CBE may include checklists and flowsheets as efficient means
of documenting that standards of care have been provided. For example, nursing assistants may document activities of daily living
(ADL) or vital signs on a flow sheet. See an example of an ADL flowsheet using the information in the following box. Keep in
mind that documentation is reviewed and submitted by agencies for insurance reimbursement, so it is imperative that charting is
accurate and up-to-date.

See a PDF example of an ADL flowchart.

In addition to documenting client cares and data collected, nursing assistants also report findings to the nurse. When observations
are normal, they can be reported at routine times such as during shift change report. However, abnormal vital signs or significant
changes in client status pertaining to breathing, circulation, cognition, pain, or falls should be immediately reported to the nurse for
rapid assessment and intervention to ensure client health and safety.
Nursing assistants use critical thinking skills to determine what should be immediately reported to the nurse. If you are unsure
about the significance of a finding, it is best to report it to the nurse and allow them to determine what is needed for the resident. It
is never incorrect to report information to the nurse. However, waiting to report an important finding can negatively impact the
client’s health, so use a cautious approach and report anything that seems out of the ordinary. As you gain experience, your critical
thinking skills will grow and improve.
Throughout this textbook, observations are described that should be immediately reported. Review Chapter 3.2 (“Emergency
Situations”) and Chapter 6.3 (“Pain”) for additional information. The “Normal Ranges for Vital Signs” section in this chapter can
be used to determine when vital signs are out of range and should be reported to the nurse.

1. This work is a derivative of Nursing Fundamentals by Open RN and is licensed under CC BY 4.0 ↵

This page titled 7.2: Documenting and Reporting Data is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra
Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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7.3: Recognizing Signs of Client Discomfort
While performing cares, obtaining vital signs, or collecting other data, the nursing assistant may notice subjective or objective signs
of discomfort in the client.
Subjective signs of discomfort are what the person reports to you such as, “My stomach hurts,” or “I feel achy when I walk.”
Subjective reports cannot be verified objectively and must be reported based on what the person communicates. For this reason,
when documenting subjective data, write exactly what the client said in quotations. For example, a nursing assistant might
document: The client stated, “My stomach hurts.”
Objective data are observable and verifiable. Nursing assistants may suspect a client is experiencing discomfort based on nonverbal
signs, such as grimacing, guarding the injured body part, rocking, rubbing the area, or moaning. When a client is unable to verbally
communicate, noticing objective signs of pain is integral for providing comfort measures and improving their quality of life.
Review the Pain Assessment in Advanced Dementia (PAINAD) in Chapter 6 (“Pain”) that is used to observe and document
objective signs of pain.

Review the concepts of objective and subjective data in the Chapter 1.5, “Guidelines for Reporting” subsection.

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upon request.

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7.4: Obtaining Vital Signs
Vital signs are taken upon admission to a facility and then routinely (e.g., weekly in long-term care settings or every shift in
inpatient care settings). They are also obtained when there is a change in client condition (e.g., a suspected infection), after a fall, or
with some medication changes.
Vital signs are taken at regular intervals to establish a client’s baseline, evaluate trends, and determine if a client is experiencing a
variance outside their normal range. Many factors can affect vital signs, including activity level, medications, recent intake, or age.
Vital signs include temperature recorded in Celsius or Fahrenheit, pulse, respiratory rate, blood pressure, and oxygen saturation
using a pulse oximeter. Obtaining a pain rating is often considered a sixth vital sign. Read about pain ratings in the “Pain” section
of Chapter 6.
[1]
See Figure 7.1 for an image of a nursing assistant obtaining vital signs. Obtaining vital signs may be delegated to a nursing
[2]
assistant for stable patients, depending on the state’s scope of practice for nurse aides and agency policy and training.

Figure 7.1 Obtaining Vital Signs

Temperature
Accurate temperature measurements provide information about a patient’s health status and guide clinical decisions made by the
nurse. For example, an elevated temperature (referred to as a fever) can indicate the client is experiencing an infection. Body
temperature is documented in degrees Celsius (ºC) or Fahrenheit (ºF).
There are several methods for measuring body temperature based on the client’s developmental age, cognitive functioning, level of
consciousness, health status, and agency policy. Common methods of temperature measurement include oral, axillary, tympanic,
rectal, and temporal routes. Each of these routes is further discussed in the following subsections, and Skills Checklists are
provided later in the chapter.
When documenting a client’s temperature, it is important to document the route used to obtain the temperature because of normal
variations in temperature in different locations of the body. For example, axillary temperature can be one degree or more lower than
an oral temperature. See normal temperature ranges according to method in Table 7.5a in the “Normal Ranges for Vital Signs”
section of this chapter.

Oral Temperature
Oral temperature is taken in the mouth under the tongue. Normal oral temperature is 35.8 – 37.3ºC (96.4 – 99.1ºF). An oral
[3]
thermometer is shown in Figure 7.2. The device has blue coloring indicating its use as an oral or axillary thermometer, as opposed
to a rectal thermometer that has red coloring. Oral temperature is reliable when it is obtained close to the sublingual artery at either
side of the base of the tongue. Some factors can cause an inaccurate measurement using the oral route. For example, if the patient
recently consumed a hot or cold food or beverage, chewed gum, or smoked prior to measurement, a falsely elevated or decreased
reading may be obtained. Oral temperature should be taken 15 to 25 minutes following consumption of a hot or cold beverage or
[4]
food or 5 minutes after chewing gum or smoking.

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 Figure 7.2 Oral Thermometer

Axillary Temperature
Axillary temperature is taken in the armpit. The axillary method is a minimally invasive way to measure temperature and is
commonly used in children or in adults with impaired cognition who may not tolerate oral or tympanic routes. It uses the same
electronic device as an oral thermometer (with blue coloring), but the probe is placed in the armpit. The axillary temperature can be
[5]
as much as one degree lower than the oral temperature. See Figure 7.3. for an image of a nursing assistant taking an axillary
[6]
temperature.

Figure 7.3 Axillary Temperature

Tympanic Temperature
Tympanic temperature is taken using a device placed in the ear. It is more accurate than oral or axillary measurement because the
tympanic membrane in the ear shares the same artery that perfuses the hypothalamus (the part of the brain that regulates the body’s
[7]
temperature). The tympanic temperature is typically 0.3 – 0.6°C higher than an oral temperature. See Figure 7.4 of a tympanic
[8]
thermometer. The tympanic method should not be used if the patient has a suspected ear infection.

Figure 7.4 Tympanic Thermometer

Rectal Temperature
Rectal temperature is taken in the rectum. It is the most accurate measurement method but is considered an invasive procedure.
Some sources suggest its use only when other methods are not appropriate. However, when measuring infant temperature, it is
considered a gold standard because of its accuracy. An adult requiring a rectal temperature should be placed in the Sims’ position.
(See Chapter 8 for positioning techniques.) The rectal temperature is usually 1ºC higher than oral temperature. A rectal
[9]
thermometer has red coloring where the probe attaches to the device to distinguish it from an oral/axillary thermometer. See
[10]
Figure 7.5 for an image of a rectal thermometer.

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 Figure 7.5 Rectal Thermometer

Temporal Temperature
Temporal temperature is taken by using a device placed on the forehead. Temporal thermometers contain an infrared scanner that
measures the heat on the surface of the skin resulting from blood moving through the temporal artery in the forehead. Temporal
temperature is typically 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature. It is a quick, noninvasive method, but accurate
[11]
measurement is dependent on good contact with the skin and good placement on the forehead. See Figure 7.6 for an image of a
temporal thermometer.

Figure 7.6 Temporal Thermometer

Pulse
Pulse refers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It can be palpated at
[12]
many points throughout the body as shown in Figure 7.7.

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 Figure 7.7 Common Pulse Assessment Locations
[13]
Nursing assistants typically obtain the radial pulse because it is easily accessible. See Figure 7.8 for an image of a nursing
assistant obtaining a radial pulse. To locate the radial pulse, ask the client to hold the palm of their hand upwards. Draw an
imaginary line from the extended index finger of the resident past the wrist to the radial bone and then palpate the radial pulse just
inside the radial bone. Use your index and third finger when palpating a pulse; never use the thumb because it has its own pulse,
and you may inadvertently count your own heart rate rather than the heart rate of the client. When obtaining a pulse, the patient
should be seated comfortably with their arms and legs uncrossed. If the patient is lying down, this may lower their heart rate so
their position should be documented.

Figure 7.8 Radial Pulse

Pulse is measured in beats per minute. The normal adult pulse rate (heart rate) at rest is 60–100 beats per minute, with different
[14]
ranges according to age. See normal pulse ranges by age in Table 7.5b in the “Normal Ranges for Vital Signs” section of this
chapter.
The pulse rate should be regular, meaning the frequency of the pulsation felt by your fingers is an even tempo with equal intervals
between pulsations. However, heart conditions can cause irregularities in heart rate, called arrhythmias. When an irregular pulse is
noted, it should be documented and reported to the nurse. It is considered best practice to assess a patient’s pulse for a full 60
[15]
seconds, especially if there is an irregularity to the rhythm.

Respiration
Respiration refers to a person’s breathing and the movement of air into and out of the lungs. Inspiration refers to the process
causing air to enter the lungs, and expiration refers to the process causing air to leave the lungs. A respiratory cycle (i.e., measured
[16]
as one breath for the respiratory rate) is one sequence of inspiration and expiration (i.e., the chest rises and falls once).
The quality of a person’s breathing is normally relaxed and silent. However, loud breathing, nasal flaring, or the use of accessory
muscles in the neck, chest, or ribs is a sign of breathing problems (referred to as respiratory distress). People who are
experiencing respiratory distress naturally assume a tripod position, meaning they lean forward and place their arms or elbows on
their knees or on a bedside table to help improve lung expansion. If a patient is demonstrating new signs of respiratory distress as
[17]
you are obtaining their vital signs, immediately notify the nurse.

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Respirations normally have a regular rhythm in children and adults who are awake. A regular rhythm means that the frequency of
the respiration follows an even tempo with equal intervals between each respiration. However, newborns and infants commonly
[18]
exhibit an irregular respiratory rhythm.
Normal respiratory rates vary based on age. The normal resting respiratory rate for adults is 10–20 breaths per minute, whereas
[19]
infants younger than one year old normally have a respiratory rate of 30–60 breaths per minute. See normal respiratory rate
ranges by age in Table 7.5c in the “Normal Ranges for Vital Signs” section of this chapter.
When obtaining a respiratory rate, the most accurate measurement is obtained when the client is not aware you are watching their
breathing; knowing they are being observed can unconsciously change their breathing pattern. For this reason, many nursing
assistants count the client’s respirations while they appear to be taking their pulse. (This is one exception to the standard rule of
explaining to the client what you will be doing.)
When counting respirations, it can be difficult to see a complete respiratory cycle. Respirations can be observed by looking at the
client’s shoulders move up and down with each breath, the stomach or chest rising and falling, or the clothing around the ribs
moving. You may have to ask the client to remain quiet while respirations are being observed because talking or moving changes
the respiratory rate. Respirations are documented as the number of breaths per minute, with each cycle of inspiration and exhalation
counting as one breath.

Blood Pressure
Blood pressure is the measurement of the force of blood against the walls of the arteries as the heart pumps blood through the
body. It is reported as millimeters of mercury (mmHg). This pressure inside the arteries changes when the heart is contracting
compared to when the heart is resting and filling with blood. For this reason, blood pressure is expressed as two numbers called
systolic pressure and diastolic pressure (e.g., 120/80). Systolic blood pressure (the top number of the fraction) is the pressure in
the arteries during systole (i.e., when the ventricles are contracting and causing the ejection of blood into the aorta and pulmonary
arteries). Diastolic blood pressure (the bottom number of the fraction) is the resting pressure in the arteries during diastole (i.e.,
[20]
the phase between each contraction of the heart when the ventricles are filling with blood).
Depending on your state’s scope of practice for nursing assistants and the training you receive at the facility where you work, you
may be delegated the task of taking blood pressure with an automated cuff. Be aware of the client’s health status because there are
circumstances when blood pressure should not be taken on a certain arm, such as an arm containing a fistula for dialysis, an
intravenous (IV) line, or implanted birth control. If the person has had a mastectomy, blood pressure should not be taken on the arm
on the side of the mastectomy.
When obtaining a blood pressure, allow the person to rest in place for a few minutes or an inaccurately high blood pressure may be
obtained due to recent activity. Position the person in a seated position with their legs and arms uncrossed and the elbow of their
arm at heart level supported by a table or your arm. Lying down or standing will change the blood pressure reading, so document if
the client is standing, sitting, or lying down when the blood pressure is measured.
Raise the client’s sleeve or assist the client to remove their arm from their sleeve. Place the artery marker on the blood pressure cuff
directly on the skin above the client’s brachial artery. To find the brachial artery, gently flex the arm and feel for the bicep muscle,
which is the larger muscle of the upper arm. The brachial artery is located towards the inside of the base of the bicep muscle.
[21]
See the different sizes of blood pressure cuffs in Figure 7.9. In adults, “regular” or “large” cuffs are typically used based on the
size of the client’s upper arm.

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 Figure 7.9 Different Sizes of Blood Pressure Cuffs
It is vital to ensure the cuff fits appropriately on the person’s arm in order to obtain an accurate blood pressure measurement. An
undersized cuff will cause an artificially high blood pressure reading, and an oversized cuff will produce an artificially low reading.
When applying the cuff to the client’s arm, the end of the cuff should be within the indicated range margins on the cuff. See Figure
[22]
7.10 for an image of the range designated on the cuff.

Figure 7.10 Range Markings to Ensure Proper Cuff Size

After the cuff is in place, press the start button on the monitor. The cuff will automatically inflate to a specific pressure and then
deflate at a rate of 2 mmHg per second. The monitor digitally displays the blood pressure reading when it is done. See Figure
[23]
7.11 for an image of an automatic blood pressure monitor. Abnormal blood pressure readings should be promptly reported to the
nurse. See normal and abnormal blood pressure ranges in Table 7.5d in the “Normal Ranges for Vital Signs” section of this chapter.

Figure 7.11 Automatic Blood Pressure Monitor

Oxygen Saturation
Patient oxygenation status is assessed routinely using pulse oximetry. Oxygen saturation, also referred to as SpO2, is a client’s
oxygenation status measured by a pulse oximeter. SpO2 estimates a person’s oxygenation level based on how much hemoglobin in
their red blood cells is “saturated” with oxygen. The target range of SpO2 for an adult is 94-98%. For patients with chronic
respiratory conditions, such as chronic obstructive pulmonary disease (COPD), their normal range for SpO2 is often lower (e.g.,
88% to 92%).

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Although SpO2 is an efficient, noninvasive method to assess a patient’s oxygenation status, it is an estimate and not always
accurate. For example, severe anemia (i.e., decreased level of hemoglobin in the blood) or decreased peripheral circulation can
[24]
cause an inaccurately low SpO2 level.
[25]
A pulse oximeter includes a sensor that measures light absorption of hemoglobin to estimate oxygen saturation. See Figure 7.12
for an image of a pulse oximeter. The sensor can be attached to the patient using a variety of devices. For intermittent measurement
of oxygen saturation, a spring-loaded clip is attached to a patient’s finger or toe. However, this clip is too large for use on newborns
and young children, so the sensor is typically taped to a finger or toe. An earlobe clip is an alternative for patients who cannot
tolerate the finger or toe clip or have a condition (such as vasoconstriction and poor peripheral perfusion) that can affect the results.
[26]
Fingernail polish causes inaccurate measurement and should be removed from the nail of the finger being used for measurement.

Figure 7.12 Pulse Oximeter

When documenting a client’s oxygen saturation level, it is vital to document if the client was receiving supplemental oxygen or if
the reading was taken while they were breathing room air. If supplemental oxygen was being provided, the type of oxygenation
device and the amount of oxygen being delivered should also be documented (e.g., “Oxygen saturation of 90% while receiving
oxygen via nasal cannula at 2 Liters/minute”).

1. “US Navy 110714-N-RM525-060 Hospitalman Seckisiesha Isaac, from New York, prepares to take a woman's temperature at a
pre-screening vital signs stat.jpg” by U.S. Navy photo by Mass Communication Specialist 2nd Class Jonathen E. Davis is
licensed under CC0 ↵
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%3A_Temperature/2.17%3A_Oral_Temperature ↵
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at
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10. “Rectal Thermometer” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
11. “49894280938_74504454c3_h” by Adafruit Industries is licensed under CC BY-NC-SA 2.0 ↵
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21. “BP-Multiple-Cuff-Sizes.jpg” by British Columbia Institute of Technology (BCIT) is licensed under CC BY 4.0. Access for
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7.5: Normal Ranges for Vital Signs
Temperature
The average body temperature is 98.6º F (37º C), but normal body temperature can range between 97º F (36.1º C) to 99º F (37.2º
C), depending on the activity level or the time of day. Older adults have lower body temperatures; a reading of 96º F (36º C) is not
unusual. See Table 7.5a for average temperature ranges according to the measurement method. In general, notify the nurse for
temperatures greater than 38º degrees C (100.4º degrees F) because this indicates a fever.
[1],[2]
Table 7.5a Normal Range of Temperatures According to Method

Method Average Range C Average Range F

Oral 35.8 – 37.3ºC 96 – 99ºF

Axillary 34.8 – 36.3ºC 94.6 – 97.3ºF

Tympanic 36.1 – 37.9ºC 96.9 – 100.2ºF

Rectal 36.8 – 38.2ºC 98.2 – 100.7ºF

Temporal 35.2 – 36.7ºC 95.3 – 98ºF

Pulse
Heart rate varies greatly from newborns to adults. In general, immediately report an adult’s pulse rate that is less than 60 or higher
than 100 to the nurse. See Table 7.5b for normal heart rate ranges by age.
[3]
Table 7.5b Normal Heart Rate Ranges by Age

Age Group Heart Rate

Preterm 120 – 180

Newborn (0 to 1 month) 100 – 160

Infant (1 to 12 months) 80 – 140

Toddler (1 to 3 years) 80 – 130

Preschool (3 to 5 years) 80 – 110

School Age (6 to 12 years) 70 – 100

Adolescents (13 to 18 years) and Adults 60 – 100

Respiration
Respiratory rate varies greatly from infants to adults. In general, report an adult’s respiratory rate immediately to the nurse if it is
less than 10 or greater than 20. See normal respiratory rate ranges by age in Table 7.5c.
[4]
Table 7.5c Respiratory Rate Ranges by Age

Age Normal Range

Newborn to one month 30 – 60

One month to one year 26 – 60

1-10 years of age 14 – 50

11-18 years of age 12 – 22

Adult (ages 18 and older) 10 – 20

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Blood Pressure
Blood pressure (BP) is categorized into three ranges: low blood pressure (hypotension), normal blood pressure, and high blood
pressure (hypertension (HTN) ). In general, 120/80 mmHg is considered a normal adult blood pressure reading. See blood
pressure ranges for adults for categories of hypotension, normal, and hypertension in Table 7.5d. Systolic and/or diastolic blood
pressure readings outside the normal range should be immediately reported to the nurse.
[5]
Table 7.5d Blood Pressure Ranges for Adults

Category Systolic Reading Diastolic Reading

Hypotension (low BP) Less than 90 mmHg Less than 60 mmHg

Normal 91-129 mmHg 61-89 mmHg

Hypertension (high BP) 130 mmHg or higher 90 mmHg or higher

1. This work is a derivative of Nursing Skills by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. RB Health Partners, Inc. (n.d.). ADL CNA flow sheet. [Form]. http://anha.org/members/documents/ADLCNAFlowSheet2.pdf ↵
3. This work is a derivative of Nursing Skills by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing Skills by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. This work is a derivative of Nursing Skills by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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7.6: Measuring Weight and Height
Height and weight are documented upon admission to a facility as a baseline measurement and then taken routinely. Accurate
weights are required for calculating medication dosages, ensuring adequate food and fluid intake, and monitoring chronic
conditions such as heart failure (because weight gain is often the first indication of an impending problem).
If a resident requires daily weights as documented in their care plan, their weight should be taken on the same scale at the same
time every day, before any food or fluids are consumed, and while wearing a similar amount of clothing. The weight is
documented, and weight changes of 3 pounds over 24 hours or 5 pounds within a week should be immediately reported to the nurse
to address any possible complications. See the “Measuring Weight for Ambulatory Residents” Skills Checklist for measuring
weight for more details.
If a resident is nonambulatory, the nursing assistant should weigh the wheelchair and any associated accessories (such as foot
pedals or a chair cushion). After the resident is dressed and groomed, the nursing assistant should bring them to the scale, obtain
[1]
the weight, and then subtract the weight of the chair and associated accessories. See Figure 7.13 for an image of weighing a
resident on a wheelchair scale.
If a resident requires transfer with a full-body mechanical lift, some lifts have a scale function that can weigh the resident as they
transfer from bed to wheelchair.

Figure 7.13 Wheelchair Scale. Used on the basis of Fair Use.

Height
Resident height is typically obtained on admission and documented in the medical record. Because height rarely changes,
measurement is rarely repeated. See the “Measuring Height for Ambulatory Residents” Skills Checklist for measuring the height of
[2]
an ambulatory person with a stadiometer. Figure 7.14 shows a person being measured with a stadiometer. If a resident is
nonambulatory or unable to stand, their height can be measured with a tape measure while they are lying in bed. Height is recorded
in inches or millimeters based on agency policy.

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 Figure 7.14 Measuring Height With a
Stadiometer. Used on the basis of Fair Use.

Body Mass Index

Nursing assistants may be asked to obtain a height and weight to calculate a resident’s Body Mass Index (BMI). Body mass index
(BMI) is a calculated measure of body fat based on a person’s height and weight. It is calculated by dividing weight in kilograms
by the square of their height in meters. BMI is used to evaluate if an individual is underweight (BMI less than 18.5), normal (BMI
18.6-24.9), overweight (BMI over 25), or obese (BMI over 30). Elevated BMI measurements are associated with cardiovascular
[3]
disease, type 2 diabetes, and other chronic diseases.

1. “HOM-2600KL-2.jpg by unknown author is used on the basis of Fair Use. ↵

2. “stadiometer-3.jpeg” by unknown author is used on the basis of Fair Use. ↵
3. This work is a derivative of StatPearls by McNeil-Masuka and Boyer and is licensed under CC BY 4.0 ↵

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7.7: Measuring Intake and Output
Nursing aides assist with documenting clients’ intake and output. Intake refers to the amount of fluids the client ingests, and output refers to the amount of fluids that leave the body. Total intake
should be nearly equal to total output every day, but some fluids, referred to as “insensible losses,” cannot be measured, such as fluids lost through the respiratory system, sweat, and stool.
Therefore, urine is the most commonly measured output. Other fluids, like wound drainage in a drainage device, are also measured.
Fluids are typically documented as milliliters (mL). See the Chapter 5.7, “Documentation of Food and Fluids” subsection for review of converting ounces to mL and additional information on
measuring intake and output.
Fluid intake is routinely documented with meal intake. Some clients with certain health conditions also have their output measured and documented every shift. Intake and output are then calculated
over a 24-hour period and monitored by the nurse. A client’s intake and output (“I&O”) may be closely monitored by the nurse due to illness, a new medication, or a circulatory or urinary
[1]
condition. See Figure 7.15 for an example of a 24-hour intake and output documentation record.

Figure 7.15 Sample Intake & Output Documentation Record

1. "Intake and Output Record.PNG" by Chippewa Valley Technical College is licensed under CC BY 4.0 ↵

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7.8: Skills Checklist- Oral, Tympanic, Axillary, Rectal and Temporal Temperatures
1. Gather Supplies: Thermometer; probe covers for oral, rectal, axillary, or tympanic thermometer. See Figure 7.16[1] at the end of
this checklist for an image of various types of thermometers.
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Oral temperature
Remove the probe from the device.
Slide a probe cover (from the attached box) onto the oral thermometer without touching the probe cover with your hands.
Place the thermometer under the client’s tongue at either side of the base of the tongue.
Instruct the person to keep their mouth closed.
Leave the thermometer in place for as long as is indicated by the device manufacturer, usually indicated by a beep.
Read the digital display of the results.
Discard the probe cover in the garbage without touching the cover.
Place the probe back into the device.
4. Tympanic temperature
Remove the tympanic thermometer from its holder.
Place a probe cover on the thermometer tip without touching the probe cover with your hands.
Ask the client to keep their head still.
For an adult or older child, gently pull the outer ear up and back to visualize the ear canal.
For an infant or child under age 3, gently pull the outer ear down.
Insert the probe just inside the ear canal.
Do not force the thermometer into the ear.
Hold the device in place until it beeps (within a few seconds after the temperature is measured).
Read the results displayed.
Discard the probe cover in the garbage without touching the cover.
Place the device back into the holder.
5. Axillary temperature
Remove the probe from the device.
Place a probe cover (from the attached box) on the thermometer without touching the cover with your hands.
Ask the client to raise their arm or gently raise their arm for them.
With the probe facing towards the back of the resident, place the thermometer probe in the armpit on bare skin as high up
into the axilla as possible.
Ask the patient to lower their arm or gently lower it for them.
Leave the device in place until it beeps, usually about 10–20 seconds.
Read the displayed results.
Discard the probe cover in the garbage without touching the cover.
Place the probe back into the device.
6. Rectal temperature (Use the red probe)
Put on gloves.

7. Position the patient:

For infants, place them in a supine position and raise their legs upwards toward their chest.
For older children and adults, assist them into a side lying position and explain the procedure.

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 Remove the probe from the device.
Place a probe cover (from the attached box) on the thermometer.
Lubricate the cover with a water-based lubricant.
Gently insert the probe 2–3 cm or less inside the anus, depending on the patient’s size.
Remove the probe when the device beeps.
Read the result.
Discard the probe cover in the trash can without touching it.
Cleanse the device as indicated by agency policy.
Remove gloves, turning them inside out and discard.
Perform hand hygiene.
8. Temporal temperature
Remove eyeglasses from the client if they are worn.
Place the sensor on their forehead, ensuring good skin contact.
Slowly slide the thermometer across the forehead to the ear, maintaining contact with the skin at all times.
Stop when the sensor reaches the hairline and read the displayed result.
9. Post-Procedure Steps:
Check for resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document temperature and report abnormal findings to the nurse.

Figure 7.16 Thermometers

[2]
View a YouTube video of an instructor demonstration of obtaining a temperature:

Obtaining a Temperature

View a YouTube video[3] of an instructor demonstration of obtaining a rectal temperature:

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 Rectal Temperature

1. "Thermometers" by Landon Cerny is licensed under CC BY 4.0 ↵

2. Chippewa Valley Technical College. (2022, December 3). Obtaining a Temperature. [Video]. YouTube. Video licensed under
CC BY 4.0. https://youtu.be/rZftX0z6aKo ↵
3. Chippewa Valley Technical College. (2023, January 5). Rectal Temperature. [Video]. YouTube. Video licensed under CC BY
4.0. https://youtu.be/LKg2OS2D3rQ ↵

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7.9: Skills Checklist- Pulse
Pulse
1. Gather Supplies: Watch or clock with a second hand
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Locate the radial pulse by placing the tips of your fingers on the side of the resident’s wrist.
Count the pulse for 60 seconds.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document pulse and report abnormal findings to the nurse.
View a YouTube video[1] of an instructor demonstration of obtaining a pulse:

Obtaining a Pulse

1. Chippewa Valley Technical College. (2022, December 3). Obtaining a Pulse. [Video]. YouTube. Video licensed under CC BY
4.0. https://youtu.be/Q82Fn8pLDtg ↵

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7.10: Skills Checklist- Respirations
1. Gather Supplies: Watch or clock with a second hand
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Count respirations for 60 seconds.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document respiratory rate and report abnormal findings to the nurse.
View a YouTube video[1] of an instructor demonstration of obtaining respirations:

Obtaining Respirations

View a YouTube video[2] of an instructor demonstrating obtaining temperature, pulse, and respirations in a sequential procedure:

Obtaining Temperature, Pulse, and Res…

Res…

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 1. Chippewa Valley Technical College. (2022, December 3). Obtaining Respirations. [Video]. YouTube. Video licensed under CC
BY 4.0. https://youtu.be/yljzSZHqbq8 ↵
2. Chippewa Valley Technical College. (2022, December 3). Obtaining Temperature, Pulse, and Respirations. [Video]. YouTube.
Video licensed under CC BY 4.0. https://youtu.be/_NRc4zEYrNI ↵

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7.11: Skills Checklist- Measuring Height for Ambulatory Residents
1. Gather Supplies: Gait belt and stadiometer
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Put nonskid footwear on the resident.
Apply a gait belt if indicated on the care plan.
If the resident is in a wheelchair, assist the resident to the stadiometer and lock the brakes.
Assist the resident to stand and walk to the stadiometer.
Slowly turn the resident so their back is near the stadiometer and they are facing away from the supporting wall.
Instruct the resident to look forward and keep their chin up.
Gently lower the stadiometer arm to the top of the resident’s head.
Note the measurement.
Raise the stadiometer arm.
Assist the resident back to the wheelchair if used.
Remove the gait belt if it was applied.
Unlock the brakes if the resident is seated in a wheelchair.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document height and report abnormal findings to the nurse.
View a YouTube video[1] of an instructor demonstration of measuring height:

Measuring Height

1. Chippewa Valley Technical College. (2022, December 3). Measuring Height. [Video]. YouTube. Video licensed under CC BY
4.0. https://youtu.be/T_h4uMnh3UA ↵

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7.12: Skills Checklist- Measuring Weight for Ambulatory Residents
1. Gather Supplies: Gait belt and scale
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Verify the resident is wearing nonskid footwear.
Balance (or zero) scale.
If the resident is in a wheelchair, apply the brakes.
Assist the resident to stand, using a gait belt as needed.
Walk the resident to the scale.
Assist the resident to step on the scale.
Check that the resident is centered on the scale.
Check that the resident has their arms at their side.
Ensure the resident is not holding on to anything that would alter the reading of the weight.
Adjust the weights until the scale is in balance or read analog scale.
Assist the resident back to a seated position.
Remove the gait belt if it was used.
Release the brakes if the resident is seated in a wheelchair.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document weight and report abnormal findings to the nurse.
[1]
View a YouTube video of an instructor demonstration of measuring weight:

Measuring Weight

1. Chippewa Valley Technical College. (2022, December 3). Measuring Weight. [Video]. YouTube. Video licensed under CC BY
4.0. https://youtu.be/QnQoEwdcG1k ↵

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7.13: Learning Activities

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7.14: VII Glossary
Axillary temperature: Temperature taken in the armpit using the same device as when taking an oral temperature. It can be as
much as one degree lower than the oral temperature.
Blood pressure: The force of blood against the walls of the arteries as the heart pumps blood through the body reported in
millimeters of mercury (mmHg). It is expressed as two numbers: systolic pressure and diastolic pressure.
Body mass index (BMI): A calculated measure of body fat based on a person’s height and weight.
Charting by exception (CBE): A common type of health care documentation where routine care is provided and notes are only
written for abnormal findings or anything out of the ordinary. It is designed to keep documentation concise and reduce the amount
of time required for documentation.
Daily weights: Client weight taken at the same time every day, on the same scale, in similar clothing, and before any food or fluids
are consumed.
Diastole: The phase between each contraction of the heart when the ventricles are filling with blood.
Diastolic blood pressure: Resting pressure within the arteries during diastole.
Hypertension (HTN): Elevated blood pressure.
Hypotension: Low blood pressure.
Insensible losses: Fluid loss that cannot be measured, such as fluids lost through the respiratory system, sweat, and stool.
Intake and output (I&O): Fluid intake and output measured and documented every shift.
Oral temperature: Temperature taken in the mouth under the tongue.
Output: Fluids that leave the body, including urine output that is measured.
Oxygen saturation (SpO2): Oxygenation status by a pulse oximeter based on how much of hemoglobin in red blood cells is
“saturated” with oxygen.
Pulse: The pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It can be palpated at many
points throughout the body.
Rectal temperature: Temperature taken in the rectum. It provides the most accurate temperature measurement but is considered an
invasive procedure.
Respirations: The movement of air into and out of the lungs. Inspiration refers to the process causing air to enter the lungs, and
expiration refers to the process causing air to leave the lungs.
Respiratory distress: Problems breathing.
Systole: The phase of the heartbeat when the ventricles contract, causing the ejection of blood into the aorta and pulmonary
arteries.
Systolic blood pressure: The maximum pressure within the arteries during systole.
Temporal temperature: Temperature taken by using a device placed on the forehead that measures the heat on the surface of the
skin resulting from blood moving through the temporal artery in the forehead.
Tripod position: A position that people experiencing respiratory distress naturally assume by leaning forward and placing their
arms or elbows on their knees or on a bedside table to help improve lung expansion.
Tympanic temperature: Temperature taken using a device placed in the ear. It is more accurate than oral or axillary measurement
because the tympanic membrane in the ear shares the same artery that perfuses the hypothalamus (the part of the brain that
regulates the body’s temperature).
Vital signs: Vital signs include temperature recorded in Celsius or Fahrenheit, pulse, respiratory rate, blood pressure, and oxygen
saturation using a pulse oximeter.

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 CHAPTER OVERVIEW

8: Utilize Principles of Mobility to Assist Clients

8.1: Introduction to Utilize Principles of Mobility to Assist Clients
8.2: Moving and Positioning Clients
8.3: Promoting Joint Mobility and Activity
8.4: Assisting Clients to Transfer
8.5: Assisting With Ambulation
8.6: Applying Prosthetics and Orthotics
8.7: Restraints and Restraint Alternatives
8.8: Skills Checklist- Positioning Supine to Lateral (Side-Lying)
8.9: Skills Checklist- Transfer From Bed to Chair With a Gait Belt
8.10: Skills Checklist- Transfer From Bed to Chair With Sit-to-Stand
8.11: Skills Checklist- Transfer From Bed to Chair With Mechanical Lift
8.12: Skills Checklist- Ambulation From Wheelchair
8.13: Learning Activities
8.14: VIII Glossary

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1
8.1: Introduction to Utilize Principles of Mobility to Assist Clients
Learning Objectives
Examine types and uses of restraining devices
Use alternatives to restraints
Assist with moving or positioning a client
Promote joint mobility, body alignment, and activity
Assist with ambulation
Use client transfer techniques
Apply prosthetic and orthotic devices

Mobility is the ability to move one’s body parts, change positions, and function safely within the environment. It is one of the most
important factors for remaining independent. Immobility, the inability to independently move and change positions, is a major
reason why people are admitted to long-term care facilities for assistance to complete their activities of daily living (ADLs).
Declining mobility can negatively affect many aspects of one’s health, especially in the musculoskeletal, respiratory,
integumentary, circulatory, and digestive systems. Complications of immobility will be further discussed in Chapter 9.
Nursing assistants (NAs) have a major responsibility for assisting clients who have decreased mobility. Some clients require minor
assistance to ambulate safely or move from their bed to a chair, whereas other clients require full assistance for repositioning in bed
and/or transferring. NAs also assist in maintaining a resident’s level of functioning by promoting joint mobility and applying
prosthetics and orthotics. This chapter will review moving and positioning clients, as well as promoting their joint mobility.
In some circumstances, medical restraints may need to be applied to clients who are at risk for hurting themselves or others. This
chapter will also review various types of restraints and how to prevent complications that can result from decreased movement.

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8.2: Moving and Positioning Clients
When a resident is admitted to a facility or begins receiving home health care, assessments are completed by health care staff
(including nurses, physical therapists, and occupational therapists) to determine their care needs. Examples of assessments include
their ability to complete hygiene and grooming needs, as well as the amount and type of assistance required to safely reposition
themselves in bed, move in and out of bed into a chair, and walk (if they are able). The findings from these assessments are
implemented into the client’s care plan that the nurse and NA carry out. Roles of various therapists will be further discussed in
Chapter 9.

Repositioning in Bed
As discussed in the “Skin Care” section in Chapter 5, clients who are immobile must be repositioned every two hours to prevent
pressure injuries and other complications of immobility that will be further discussed in Chapter 9. Moving residents must be done
carefully because their skin can easily be damaged by improper handling. Due to the effects of aging on the integumentary system,
older adults can develop pressure injuries from friction and shear when repositioned or from lying in one position for long periods
of time in bed. Pressure injuries (formerly called pressure ulcers or bedsores) are localized damage to the skin or underlying soft
[1]
tissue, usually over a bony prominence, as a result of intense and prolonged pressure and/or shear.
Shear happens when skin moves one way but the underlying bone and muscle stay fixed or move the opposite direction. Shear can
occur when an individual sits up in a bed, chair, or wheelchair, and gravity causes the bone and muscle to slide down while the skin
is pulled in the opposite direction by the sheets or clothing. Friction is caused when skin is rubbed by clothing, linens, or another
body part and can cause chafing. Chafing typically occurs when the skin has inadequate moisture. See an illustration of sheer and
[2]
friction in Figure 8.1.

Figure 8.1 Friction and Shear Causing Pressure Injuries

For additional information on friction and shear, visit the Wound Care Education Institute’s Friction vs. Shearing in Wound
Care web page.

To prevent friction and shear, residents should be moved in bed with a lift sheet. The lift sheet, also called a draw sheet, is placed
between the resident and the bottom or fitted sheet. (Review types of linens in “Making an Unoccupied Bed Checklist” in Chapter
3.) The lift sheet protects the client’s skin by creating a barrier when the client is moved so the friction that occurs happens between
the lift sheet and fitted sheet rather than the resident’s skin and the fitted sheet. Lift sheets also protect the client’s skin from
bruising and skin tears that can occur when moving the client by assistants putting their hands directly on a client’s limbs. A skin
tear is a separation of skin layers caused by shear, friction, and/or blunt force. Lift sheets should always be used to reposition a
client who requires assistance, and failing to do so is considered neglectful due to the high probability of skin injury. See Figure
[3]
8.2 for an image of boosting a resident in bed with a lift sheet.

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 Figure 8.2 Boosting a Resident in Bed With a Lift Sheet
[4]
The steps for boosting a client up in bed include the following components :
Explain to the patient what will happen and how the patient can help.
Perform hand hygiene.
Raise the bed to a safe working height and ensure that the brakes are applied.
Position the patient in the supine position with the bed flat. Place a pillow at the head of the bed and against the headboard to
prevent accidentally bumping the patient’s head on the headboard.
Stand with your feet shoulder width apart at the bedside between the client’s shoulders and hips with a second assistant in a
similar position on the other side of the bed. This position keeps the heaviest part of the client closest to the center of gravity of
the assistants.
Fan-fold the lift sheet toward the patient with your palms facing upwards. This provides a strong grip to move the client up with
the lift sheet.
Ask the patient to tilt their head toward their chest, fold their arms across their chest, and bend their knees to assist with the
movement. Let the patient know the move will happen on the count of three. This step prevents injury from occurring to the
patient and prepares them for the move.
Tighten your gluteal and abdominal muscles, bend your knees, and keep your back straight and neutral. Face toward the
direction of movement. Using proper body mechanics can help prevent back injury when used appropriately in patient-care
situations.
On the count of three by the lead person, gently slide (not lift) the patient toward the head of the bed, shifting your weight from
the foot closest to the end of the bed to the foot closest to the head of the bed, while keeping your back straight and knees
slightly bent.
Replace the pillow under the patient’s head, move them into a different position as indicated, and cover them with a sheet or
blanket per their preference.
Check the patent’s comfort and for proper alignment.
Ensure the patient remains in the middle of the bed.
Lower the bed, check that the brakes are locked, and ensure the call light is within reach. Perform hand hygiene.
Document or report any skin issues or other observed changes with the patient.

Review the “Body Mechanics and Safe Equipment Use” section in Chapter 3 to prevent yourself from injury during
repositioning.

Pressure injuries are preventable by repositioning clients at least every two hours and reporting any skin redness or other changes to
the nurse for additional interventions. There are several positions that can be used to relieve pressure points and keep residents safe
from pressure injuries. Repositioning also promotes improved circulation through movement. Positions are described in the various
“Positions” subsections below.
When a resident has an existing pressure injury or a susceptible area, an hourly repositioning schedule is typically implemented
(rather than the standard two-hour repositioning schedule considered routine care for all residents requiring assistance with their
mobility). Repositioning a client every hour should be documented, indicating the time and the positions the resident was moved
from and placed into. An example of documentation is, “At 1400, the resident was repositioned from a right side-lying position to a
supine position.”

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Body Alignment for Positioning Residents
Similar to how nursing assistants use good body alignment (i.e., good posture) to prevent musculoskeletal injuries to themselves,
the same principle should also be applied to residents. Good body alignment not only prevents injury, but also promotes comfort for
residents. After repositioning a resident, the NA should stand at the foot of the bed and verify that the resident’s spinal column is
straight and parallel to the sides of the bed, as well as ensuring the resident is lying in the middle of the bed (to reduce the risk of
[5]
accidentally rolling out of bed). See Figure 8.3 of an image of a properly aligned mannequin in the lateral position.

Figure 8.3 Properly Aligned Lateral Position

Pressure Relieving Devices

In addition to being caused by friction and shear, pressure injuries can occur in high-risk areas such as bony prominences or where
a bone is lying directly on top of another bone. Bony prominences are the areas of the body where a bone lies close to the skin’s
surface, such as the back of the head, shoulders, elbows, heels, ankles, tops of the toes, hips, and coccyx (i.e., tailbone). These areas
are most susceptible to developing pressure injuries because they have the least amount of cushioning. Placing pillows or other
specialized equipment reduces the pressure in these areas and also helps to prevent the resident from rolling out of position.
There are different sizes of pillows and equipment available in facilities to relieve pressure, prevent rolling, and increase client
comfort. For example, foam wedges are placed behind a patient’s back to prevent them from returning to the supine position or
[6]
rolling close to the edge of the bed. See Figure 8.4 for images of a wedge cushion and a client positioned using a wedge cushion.

Figure 8.4 Wedge Cushion Used for Positioning

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Positions
Common positions used for repositioning patients are supine, Fowler’s, lateral, Sims’, and prone positions.

Supine Position
The most common sleeping position is the supine position, where the client is lying flat on their back as demonstrated in Figure
[7]
8.5. Pillows or wedges can be placed on each side of the resident to promote comfort or to support a limb that is immobile or has
impaired function. A pillow should also be placed underneath their calves to keep their heels off the bed and prevent pressure that
can cause pressure injuries. (This pillow placement under the calves is often referred to as “floating the heels.”) After repositioning
the client, the NA should be able to place their hand underneath the client’s heels to verify there is no contact by the heels on the
mattress.

Figure 8.5 Supine Position

If a resident is highly susceptible to pressure injuries of the heels, they may have specialized soft foam boots, as illustrated in
[8]
Figure 8.6, that support the ankles and keep the heels floated off the bed. A foot cradle may also be used to keep sheets and
blankets off the tops of the toes if the resident has a history of skin injury in that area.

Figure 8.6 Inside of Foam Boot (left) and a Foam Boot Supporting a Heel

Fowler’s Position
In Fowler’s position, the client is lying on their back with their head elevated between 30 and 90 degrees, as illustrated in Figure
[9]
8.7. Residents should be placed in Fowler’s position any time they are eating or drinking or when oral care is provided. Fowler’s
position is also used to increase lung expansion for those with breathing difficulties, such as those that occur with heart failure. It
may also be used for comfort during leisure activities such as watching television or reading. Additionally, residents receiving tube
feeding should never have their head placed below a 30-degree angle because this can cause aspiration of the fluids.
However, Fowler’s position increases the risk of friction and shear on the coccyx and gluteal muscles as the client slides down in
bed. This risk can be reduced by concurrently raising the lower portion of the bed or by putting multiple pillows below the lower
legs. These actions bend the knees and reduce the pull of gravity that causes the resident to slide down in bed. A pillow can also be
placed below the feet to prevent them from contacting the foot of the bed.

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 Figure 8.7 Fowler’s Position

Lateral or Side-Lying Position

[10]
Lateral (side-lying) position places the resident on their left or right side as shown in Figure 8.8. This position relieves pressure
on the coccyx and can increase blood flow to the fetus in pregnant women. The top arm and leg can be placed in a flexed position
in any range that is comfortable to the resident. Supports should be placed behind the back to keep the resident from rolling to the
supine position. Additionally, supports should be placed between the top knee and the bed or other knee and between the top elbow
and rib cage or the bed, depending on the location of the elbow joint. These supports will alleviate pressure between the bony
prominences in these areas. The pillow underneath the resident’s head should also be adjusted for comfort and alignment checked
from the foot of the bed.
The most common rotation of positions for repositioning residents is to rotate them from supine position to lateral position, to
supine position, to lateral position on the opposite side. See the “Positioning Supine to Lateral (Side-Lying) Skills Checklist” for
the steps to move a resident from the supine to lateral (side-lying) position.

Figure 8.8 Lateral (Side-Lying) Position

Sims’ Position
Sims' position is very similar to the lateral position, but the client is always placed on their left side and their left arm is placed
behind the body (rather than in front of the body). Sims’ position is commonly used for administration of a suppository or an
enema. Depending on your state’s scope of practice, you may be delegated to give an enema, or the nurse may ask you to prepare
[11]
the patient for an enema by placing them in the Sims’ position as pictured in Figure 8.9.

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 Figure 8.9 Sim’s Position

Prone Position
[12]
In the prone position, the client is placed on their stomach with their head turned to one side, as seen in Figure 8.10. Pillows
should be placed underneath the shins to relieve pressure. Pillows (or wedges) can also be placed on both sides of the patient, and
the head pillow should be readjusted for comfort.
Prone is the least commonly used position, especially in older adults due to their neck immobility. This position may be used for a
client with a surgical wound on the back side of their body or to improve respiratory status in clients with respiratory conditions
like COVID-19.

Figure 8.10 Prone Position

1. Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised national pressure ulcer
advisory panel pressure injury staging system: Revised pressure injury staging system. Journal of Wound, Ostomy, and
Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597.
https://doi.org/10.1097/WON.0000000000000281 ↵
2. “Shear Force” and “Shear Force Closeup” by Meredith Pomietlo at Chippewa Valley Technical College are licensed under CC
BY 4.0 ↵
3. “Book-pictures-2015-572.jpg” by unknown author is licensed under CC BY 4.0. Access for free at
https://opentextbc.ca/clinicalskills/chapter/3-5-positioning-a-patient-on-the-side-of-a-bed/ ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. “Lateral Position.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
6. “9d798f98-18fb-44b4-8226-b66dc0162fdf.47775a4c216eed6da1309a7a32a640ae” ↵
7. “supine.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-4-
positioning-a-patient-in-bed/ ↵
8. “Foam Boot” and “Foam Boot Supporting a Heel” by Myra Reuter for Chippewa Valley Technical College is licensed under CC
BY 4.0 ↵
9. “degreeLow.jpg” by unknown author is licensed under CC BY 4.0. Access for free at
https://opentextbc.ca/clinicalskills/chapter/3-4-positioning-a-patient-in-bed/ ↵
10. “lateral.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-4-
positioning-a-patient-in-bed/ ↵
11. “sims.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-4-
positioning-a-patient-in-bed/ ↵

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12. “prone.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-4-
positioning-a-patient-in-bed/ ↵

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8.3: Promoting Joint Mobility and Activity
Actions for maintaining the musculoskeletal system and preventing complications will be discussed in Chapter 11. These actions
can be summarized by the phrase, “Use it or lose it,” meaning the functioning of the musculoskeletal system declines quickly when
it is not being used. Small, everyday activities help maintain flexibility in joints, muscle strength, and healthy bone density. The
NA can help residents maintain their musculoskeletal health by encouraging them to do as many activities for themselves as
possible.
While it may be faster to perform ADLs for a resident, allowing them to provide care for themselves not only maintains
musculoskeletal function but also gives them a sense of control that can enhance their self-esteem and quality of life. Here are ways
NAs can encourage residents to participate in their self-cares:
Allow residents to dress themselves to maintain flexibility in their shoulders, wrists, hips, and knee joints. Using buttons and
zippers helps to maintain flexibility in the fingers, as well as promoting hand-eye coordination.
When toileting a resident, encourage them to walk into the bathroom rather than bringing them in their wheelchair to the toilet
or commode.
Encourage residents to walk to meals (with assistance as needed) rather than being transported by wheelchair.
Play board games or card games to promote upper body mobility, as well as to stimulate their cognitive status.
Encourage residents to feed themselves. If they require extensive assistance, offer finger foods they can hold and eat more
easily.
Ask residents to wash their face, brush their teeth, or shave. Prepare the soap and washcloth, toothbrush and toothpaste, or
razor, and assist in completing the task as needed.
If a resident can’t walk, take off the foot pedals from their wheelchair (if it is safe to do so). Encourage them to move their feet
while sitting to propel themselves around the facility independently.
Inform residents of scheduled daily activities and promote movement and social interaction.

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8.4: Assisting Clients to Transfer
It is important to note that most injuries that happen to clients and staff occur when clients are being transferred. Safety is an integral component of moving clients and should receive the highest
priority. Special consideration should be given to these items to prevent injury from occurring:
Gait belt fit and placement
Brakes on the bed
Brakes on the wheelchair
Brakes released on the lift
Placement of nonskid footwear
Resident’s proximity to the lift
Objects in the room that may be a hazard during the movement
Nursing assistants should always review a client’s care plan for their current transfer status before moving them. Transfer status refers to how a resident moves from one place to the other, such as
from a bed to wheelchair or wheelchair to toilet. Physical therapists (i.e., health specialists who evaluate and treat movement disorders) assess clients and make recommendations for how clients
should be safely transferred. Transfer status orders are determined by how much body weight a client can independently bear and how much weight an assistant is required to support. Transfer status
orders include these types of orders:
Independent: The client requires no assistance to move from one place to another.
Contact-Guard-Assist (CGA): One assistant must have their hand on the client at all times to steady their balance.
1 assist (1A): One assistant is required to help the resident transfer (with a gait belt in place).
2 assist (2A): Two assistants are required to help the resident transfer (with a gait belt in place).
Sit-to-Stand: A sit-to-stand mechanical lift is required to help a resident transfer. A sit-to-stand mechanical lift provides support as the client stands while allowing them to bear some body
weight and maintain joint mobility and leg strength. (Using a gait belt would require extensive assistance and could cause injury to the client or the staff.) Sit-to-stands may be completed with
one or two assistants, as determined by the physical therapist and agency policy.
Full-Body Mechanical Lift: A full-body mechanical lift is required when the resident cannot bear any of their weight when transferred from bed to chair and back. (“Full-body mechanical lift”
is a generic term. The facility or organization may refer to this type of lift by the manufacturer of the lift, such as a “Hoyer lift” or “PAL lift.”) Full-body mechanical lifts may be portable or
attached to the ceiling. Two assistants are always required for transfer with full-body mechanical lifts for safety purposes. Due to federal liability laws, the health care professional moving the lift
must be 18 years of age or older.

Assisting to Seated Position or Dangling

When transferring a client using a 1A, 2A, or sit-to-stand transfer method, first assist the resident to move to a seated position on the side of their bed. Residents who can transfer with one of these
methods are able to bear some or most of their weight and should be able to move partially on their own. Use your hands on the person’s limbs to direct the movement, and use the lift sheet (similar
to when boosting a client up in bed).
Due to heart and circulation changes that occur with age, orthostatic hypotension can occur when a person moves suddenly from a lying to sitting position or from a sitting to standing position.
Orthostatic hypotension is a sudden drop in blood pressure that can cause clients to feel dizzy and increase their risk for falls with position changes. Some clients may experience vertigo, a
sensation that the room is spinning. To prevent orthostatic hypotension and these symptoms, tell the person to dangle (i.e., sit up on the edge of the bed) for a few moments before continuing with
the transfer. Dangling gives the cardiovascular system time to regulate blood pressure and blood flow to the brain, thus preventing dizziness and falls. Ask the client if they are feeling dizzy before
[1] [2]
you proceed with transferring. See Figure 8.11 for illustration of the steps to safely assist a client to a seated position :
Lock the brakes on the bed.
Raise the bed to a working height.
Stand facing the head of the bed at a 45-degree angle with your feet apart, with one foot in front of the other. Stand next to the waist of the resident.
Ask the resident to turn onto their side, facing you, as they move closer to the edge of the bed. Use the lift sheet to assist the resident if needed.
Place one hand behind the resident’s shoulders, supporting their neck and vertebrae.
Place the other hand around the resident’s knees.
On the count of three, instruct the resident to use their elbows to push up against the bed and then grasp the side rail. Support their shoulders as they move to a seated position. Shift your weight
from the front foot to the back foot as you assist them to sit. Do not allow the resident to place their arms around your shoulders because this can cause serious back injuries.
As you shift your weight, gently grasp the resident’s outer thighs with your other hand and help them slide their feet off the bed to dangle or touch the floor. This step helps the resident sit and
move their legs off the bed at the same time. As you perform this action, bend your knees and keep your back straight and neutral. Move the resident as one entire unit (rather than the upper body
followed by the lower body).
Lower the bed so the resident’s feet touch the floor.
Observe the resident for symptoms of orthostatic hypotension or vertigo. Ask if they are feeling dizzy before attempting any further movement.
Check that the resident is wearing nonskid footwear before transferring.

Figure 8.11 Assisting a Resident to a Seated Position

If the resident is having difficulty moving during this procedure, use the lift sheet to pull them closer to you or to assist them from a lying to a seated position. The head of the bed can be raised
before they turn on their side to support their core strength and to reduce the weight the assistant must bear. During this entire process, do not use the resident’s limbs to move them but rather move
them with the trunk of their body to prevent shear and injury to their limbs and skin.
After the person is sitting upright and states they are not experiencing dizziness, apply a gait belt for a 1A or 2A transfer. The gait belt should be placed around their waist while considering the
[3]
location of their breasts and abdominal folds. See Figure 8.12 for an image of applying a gait belt. The fit of the gait belt should be snug, but you should be able to put your fingers underneath the
gait belt for support. As the resident stands and their core muscles contract, the gait belt can loosen and tend to slide up, so it is important for it to be snug. If the belt is too long, it can get caught in
the patient’s legs during transfer, so tuck the excess length back into the belt. Gait belts should not be used for clients with abdominal wounds or some types of heart conditions; a different transfer
method should be in the care plan. Contact the nurse if you have concerns about using a gait belt based on the client’s condition.

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Place nonskid footwear on the resident before transferring them from the bed to the chair. These preparations should be done before the wheelchair or sit-to-stand is brought closer to the bed to
reduce the risk of injury from the resident inadvertently hitting the lift or chair while moving.
The steps to complete a one person assist (1A) are listed in the “Transfer From Bed to Chair With a Gait Belt” Skills Checklist. If a two-person assist (2A) is required, the same steps are used, but
the assistants stand on each side of the resident to provide additional support during the transfer.

Figure 8.12 Applying a Gait Belt

[4]
View the following video showing a transfer of a patient from a bed to a regular chair : Assisting From Bed to Chair With a Gait Belt or Transfer Belt.

Transferring with Mechanical Lifts

[5]
Mechanical lifts include sit-to-stand lifts and full-body lifts. Some facilities have full-body mechanical lifts that are attached to the ceiling of the room. See Figure 8.13 of an image of a sit-to-stand
[6]
lift and Figure 8.14 of an image of a full-body mechanical lift and mechanical swing. NAs should be aware of agency policy regarding transferring clients using mechanical lifts; for safety
purposes, most agencies require two NAs or a nurse and an NA to transfer clients using a mechanical lift.

Figure 8.13 Sit-to-Stand Lift

Figure 8.14 Full-Body Mechanical Lift and Mechanical Sling

[7]
The legs of portable full-body mechanical lifts can be placed in a closed or open position. The open position provides the greatest stability due to a wide base of support. See Figure 8.15 for an
image comparing the legs of a portable full-body mechanical lift in a closed and open position.

Figure 8.15 Portable Full-Body Mechanical Lift With Legs in a.) Closed Position
and b.) Open Position
When transferring a client from their bed to wheelchair using a sit-to-stand or portable full-body mechanical lift, the wheelchair should be positioned near the bed while also allowing enough room
for the lift to rotate towards the chair. Because the lift will have to slide underneath the bed, check for any cords or equipment under the bed that can cause the lift to get tangled. Raising the bed
height just before placing the lift under the bed should also alleviate potential problems.
The lift has greatest stability when its legs are open with a wide base of support, but some beds do not have enough space underneath to allow the legs to be open. If this is the case, open the legs as
soon as possible when moving the lift from under the bed to provide a stable base.
Sit-to-stand and full-body lifts have brakes, but brakes should not be applied when the resident is standing in the sit-to-stand or raised off the bed in a full-body lift. (If the client’s weight shifts while
the brakes are on, it can cause the lift to tip and endanger the resident, as well as the assistants.)
Before initiating a transfer, verify that the lift will support the weight of the resident. Most mechanical lifts have a weight capacity of 400 pounds. Bariatric lifts are used to support a client
[8]
weighing 600 or more pounds. See Figure 8.16 for locating the weight capacity on a lift.

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 Figure 8.16 Weight Capacity of a Mechanical Lift
Full-body mechanical lifts have different types of slings used to lift the client. Slings may be full-body or split-leg (butterfly). The type of sling used is determined by the physical therapist, based on
the client’s strength and mobility, and should be noted in the resident’s care plan. A sling has various loops to connect it to the lift and are often color-coded to ensure the resident’s body is in proper
[9] [10]
position for transferring. See Figure 8.17 for images of a full-body sling and Figure 8.18 for images of a split-leg (butterfly) sling.

Figure 8.17 a.) Front of Full-Body Sling; b.) Back of Full-Body Sling; c.) Loops (right)

Figure 8.18 a.) Front of Split-Leg (Butterfly) Sling and b.) Back of Split-Leg (Butterly) Sling
The top of a full-body sling should be placed above the resident’s head and should end just above the knee joint to avoid hyperextending the knees when they are suspended in the lift. The top of a
split-leg (butterfly) sling should be placed at shoulder height, and the bottom of the sling should be around the buttocks. Depending on hip mobility, the split-leg sling may be crossed between the
[11] [12]
client’s legs or placed around their legs (often referred to as a “basket”). See Figure 8.19 for an image of a mannequin prepared to transfer using a crossed sling and Figure 8.20 for an image of
transferring a mannequin with the sling wrapped around their legs (i.e., a “basket” approach).

Figure 8.19 a.) Preparing to Transfer With Crossed Sling and b.) Suspended in a Crossed
Sling

Figure 8.20 a.) Preparing to Transfer With a “Basket” Approach b.) Suspended in a Sling
With a “Basket” Approach
The handles of the sling should face away from the client, allowing the assistants to position the client in their chair or bed. (Do not move clients by directly contacting their limbs because this can
cause injury.)
After transferring a client from a bed to a chair using a full-body sling, the sling should remain under the resident while they are seated in a wheelchair or other chair. When placing the resident back
in bed, the sling is then removed. However, when transferring a client using a split-leg (butterfly) sling, it can be removed from underneath the client in the chair and replaced before they are
transferred again.

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See the Skills Checklists “Transfer From Bed to Chair With Sit-to-Stand” and “Transfer From Bed to Chair With Mechanical Lift” for steps for providing safe transfers with both types of lifts. Each
brand of sit-to-stand and mechanical lift has some variances; the facility where you work will provide specific training on their lifts.

[13]
Watch the following YouTube video for a demonstration of moving a resident with a sit-to-stand : Aidacare Training Video – Manual Handling – Sit To Stand.
[14]
Explore the following YouTube video on a mechanical lift completed with a butterfly or split-leg sling: Aidacare Training Video – Manual Handling – Lie To Sit

1. “Book-pictures-2015-5851.jpg,” “Book-pictures-2015-587.jpg,” and “Book-pictures-2015-588.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at
https://opentextbc.ca/clinicalskills/chapter/3-5-positioning-a-patient-on-the-side-of-a-bed/ ↵
2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
3. “Sept-22-2015-119.jpg” and “Sept-22-2015-121-001.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-5-positioning-a-
patient-on-the-side-of-a-bed/ ↵
4. Thompson Rivers University Open Learning. (n.d.). Assisting from bed to chair with a gait belt or transfer belt [Video]. Thompson Rivers University Open Learning. All rights reserved.
https://barabus.tru.ca/nursing/assisting_from_bed.html ↵
5. "Transferring Client Using a Sit to Stand" by Landon Cerny is licensed under CC BY 4.0 ↵
6. "Transferring a Client Using a Mechanical Lift and a Full Body Sling", "Transferring a Client Using a Mechanical Lift and a Split Leg Sling", and "Transferring a Client Using a Mechanical Lift
and Split Leg Sling in a Basket Approach" by Landon Cerny are licensed under CC BY 4.0 ↵
7. “Portable Full-Body Mechanical Lift With Legs in Closed Position” and “Portable Full-Body Mechanical Lift With Legs in Open Position” by Myra Reuter for Chippewa Valley Technical
College are licensed under CC BY 4.0 ↵
8. “Weight Capacity of a Mechanical Lift” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
9. “Front of Full-Body Sling,” “Back of Full-Body Sling,” and “Loops” by Myra Reuter for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵
10. “Front of Full-Body Sling,” “Back of Full-Body Sling,” and “Loops” by Myra Reuter for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵
11. “Preparing to Transfer With Crossed Sling” and “Suspended in a Crossed Sling” by Myra Reuter for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵
12. “Preparing to Transfer With a ‘Basket’ Approach” and “Suspended in a Sling With a ‘Basket’ Approach” by Myra Reuter for Chippewa Valley Technical College are licensed under CC BY 4.0
↵
13. Aidacare. (2017, July 5). Aidacare training video - Manual handling - Sit To stand [Video]. YouTube. All rights reserved. https://youtu.be/L914lkoub6E ↵
14. Aidacare. (2017, July 5). Aidacare training video – Manual handling – Lie to sit [Video]. YouTube. All rights reserved. https://youtu.be/3GOgp_HX4JQ ↵

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the LibreTexts platform; a detailed edit history is available upon request.

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8.5: Assisting With Ambulation
Ambulation is the medical term used for walking. Ambulation provides weight-bearing activity that promotes bone health and
joint mobility. A physical therapist will determine if a person can safely walk independently, with the assistance of one or two
people, or if they require an assistive device such as a cane or walker. This information is documented in their nursing care plan.
Similar to when assisting a client to transfer with a gait belt, the nursing assistant should place nonskid footwear on the person and
allow them to dangle on the edge of the bed before standing to ambulate. For specific steps, see the “Ambulation From
Wheelchair” Skills Checklist.
If a resident requires assistance with a cane, the cane should be placed on the resident’s stronger side. The resident should step
forward with the strong leg and then use the cane and the weaker leg for the next step.
There are three types of walkers: a standard walker, a two-wheeled walker (2WW), and a four-wheeled walker (4WW). The type of
walker a resident should use is recommended by the physical therapist. A 2WW or standard walker allows for more support and a
slower gait, whereas a 4WW is used by clients with better balance and mobility.
View a YouTube video[1] of an instructor demonstrating helping clients with ambulatory assistive devices:

Ambulatory Assistive Devices

Regardless of the assistive device used for ambulation, the NA should remind the resident to stand up straight and look forward
when walking. The resident should be encouraged to take purposeful steps and to not shuffle their feet. The NA should stand to one
side of the resident and slightly behind them, with one hand on their gait belt. If the resident has a weaker side, the NA should stand
on that side. The NA’s fingertips should be facing upwards underneath the gait belt for proper support. If the resident loses their
balance while in this position, the NA’s arm will allow them to use their bicep muscle, rather than their forearm, to steady the
client. The bicep is larger and stronger than the forearm and can provide better support.
A second staff member can follow a resident who is ambulating with assistance with their wheelchair in case they experience
weakness or dizziness. If the client needs to sit while ambulating, the wheelchair brakes should be applied before they sit, or in an
emergent situation, the NA should block the back of the wheelchair with their body to ensure stability when the resident sits.
If a resident starts to fall while standing or ambulating, do not attempt to stop their fall or catch the resident because this can cause
you to injure your back. Instead, move behind the patient and take one step back with one leg so you have a wide base of support.
Support the patient around their waist or hip area or grab the gait belt. Bend one of your legs and place it between the patient’s legs
from behind. Slowly slide the patient down your bent leg, lowering yourself to the floor at the same time. Always protect the
resident’s head to prevent head injury. After the resident is on the floor, do not move them. For witnessed or unwitnessed falls,
notify the nurse immediately for assessment. After the nurse has completed the assessment and met the resident’s immediate needs,
use a mechanical lift to transfer the resident back to a wheelchair or bed. An incident report will be completed by the nurse, and the
[2] [3]
NA will be asked to give a statement on what occurred and their actions in response to the situation. See Figure 8.21 for an
image of lowering a resident who is falling to the floor.

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 Figure 8.21 Lowering a Client Who is Falling to the Floor

1. Chippewa Valley Technical College. (2022, December 3). Ambulatory Assistive Devices. [Video]. YouTube. Video licensed
under CC BY 4.0. https://youtu.be/ATn7OOP4Jko ↵
2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
3. “Sept-22-2015-132-001.jpg” and “Sept-22-2015-133.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at
https://opentextbc.ca/clinicalskills/chapter/3-7-fall-prevention/ ↵

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Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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8.6: Applying Prosthetics and Orthotics
[1]
Prosthetics are an addition or attachment to the body that replicates the function of a lost or dysfunctional limb. An orthotic is a
support, brace, or splint used to support, align, prevent, or correct the function of movable parts of the body. Shoe inserts are the
most common orthotics and are intended to correct an abnormal or irregular walking pattern. Other orthotics include neck braces,
[2]
back supports, knee braces, and wrist supports. NAs apply prosthetics and orthotics to residents following the therapist’s
instructions. Incorrectly applying these devices can cause harm or injury to the resident, so you must understand the correct
placement of these supports. If you are unsure, seek guidance from your supervising nurse before placing any prosthetics or
orthotics.
One of the main concerns with prosthetic or orthotic devices is skin irritation. Prosthetics typically have a protective sleeve that
goes over the limb prior to placing the device. The sleeve gives the prosthetic some security to prevent displacement while also
protecting the skin. After the prosthetic is attached, always ask the resident if it is comfortable or if they feel any areas of pressure
that may damage the skin. Most orthotics, splints, or braces are padded, but some can be applied over thin clothing. Be sure to
review the resident’s nursing care plan regarding how long and at what times any supportive devices should be worn and removed.
[3]
See Figure 8.22 for a device that prevents foot drop.

Figure 8.22 Supportive Brace to Prevent

Foot Drop

1. Vinjamuri, R. (Ed.). (2020). Prosthesis. IntechOpen. https://doi.org/10.5772/intechopen.73978 ↵

2. Stoppler, M. C. (Ed.). (2021, March 29). Medical definition of orthotic. MedicineNet.
https://www.medicinenet.com/orthotic/definition.htm ↵
3. “AFO_Ankle_Foot_Orthosis_Orthotic_Brace.JPG” by Pagemaker787 is licensed under CC BY-SA 4.0 ↵

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8.7: Restraints and Restraint Alternatives
Restraints are devices used in health care settings to prevent patients from causing harm to themselves or others when alternative
interventions have not been effective. A restraint is a device, method, or process that is used for the specific purpose of restricting
a patient’s freedom of movement. While restraints are typically used in acute care settings, they may be used in some circumstances
in long-term care settings for safety purposes. However, restraints restrict mobility and can affect a client’s dignity, self-esteem, and
quality of life; every possible measure to ensure safety should be considered before a restraint is implemented. An order from a
[1]
health care provider is required to implement a restraint, and agency policy must be strictly followed.
Restraints include physical devices (such as a tie wrist device), chemical restraints, or seclusion. The Joint Commission defines a
chemical restraint as a drug used to manage a patient’s behavior, restrict the patient’s freedom of movement, or impair the
patient’s ability to appropriately interact with their surroundings that is not standard treatment or dosage for the patient’s condition.
It is important to note that the definition states the medication “is not standard treatment or dosage for the patient’s condition.”
Seclusion is defined as the confinement of a patient in a locked room from which they cannot exit on their own. It is generally used
as a method of discipline, convenience, or coercion. Seclusion limits freedom of movement because, although the patient is not
[2]
mechanically or chemically restrained, they cannot leave the area.
Although restraints are used with the intention to keep a patient safe, they impact a patient’s psychological safety and dignity and
can cause additional safety issues and, in some cases, death. A restrained person has a natural tendency to struggle and try to
remove the restraint and can fall or become fatally entangled in the restraint. Furthermore, immobility that results from the use of
restraints can cause pressure injuries, contractures, and muscle loss. Restraints take a large emotional toll on the patient’s self-
[3]
esteem and may cause humiliation, fear, and anger.

Restraint Guidelines
The American Nurses Association (ANA) has established evidence-based guidelines that a restraint-free environment is considered
the standard of care. The ANA encourages the reduction of patient restraints and seclusion in all health care settings. Restraining or
secluding patients is viewed as contrary to the goals and ethical traditions of nursing because it violates the fundamental patient
rights of autonomy and dignity. However, the ANA also recognizes there are times when there is no viable option other than
restraints to keep a patient safe, such as during an acute psychotic episode when patient and staff safety are in jeopardy due to
aggression or assault. The ANA also states that restraints may be justified in some patients with severe dementia or delirium when
[4]
they are at risk for serious injuries such as a hip fracture due to falling.
The ANA provides the following guidelines: When restraint is necessary, documentation of application of the restraint should be
done by more than one witness. Once restrained, the patient should be treated with humane care that preserves human dignity. In
those instances where restraint, seclusion, or therapeutic holding is determined to be clinically appropriate and adequately justified,
registered nurses who possess the necessary knowledge and skills to effectively manage the situation must be actively involved in
the assessment, implementation, and evaluation of the selected emergency measure, adhering to federal regulations and the
[5]
standards of The Joint Commission regarding appropriate use of restraints and seclusion.
Nursing documentation is vital when restraints are applied and includes information such as patient behavior necessitating the
restraint, alternatives to restraints that were attempted, the type of restraint used, the time it was applied, the location of the
restraint, and patient education regarding the restraint. Frequent monitoring according to agency guidelines and provision of basic
[6]
needs (food, fluids, and toileting) must also be documented.
Any health care facility that accepts Medicare and Medicaid reimbursement must follow federal guidelines for the use of restraints.
[7]
These guidelines include the following :
When a restraint is the only viable option, it must be discontinued at the earliest possible time.
Orders for the use of seclusion or restraint can never be written as a standing order or PRN (as needed).
The treating physician must be consulted as soon as possible if the restraint or seclusion is not ordered by the patient’s treating
physician.
A physician or licensed independent practitioner must see and evaluate the need for the restraint or seclusion within one hour
after the initiation.
The patient in seclusion or restraints must be routinely monitored according to agency policy. Generally, the best practice for
physical restraints is continuous visual monitoring or visual checks at least every 15 minutes. Some agencies require a 1:1

8.7.1 https://med.libretexts.org/@go/page/70394
 patient sitter when restraints are applied. Physical restraints should be removed every 1 to 2 hours for range of motion exercise
and skin checks.
Each written order for a physical restraint or seclusion is limited to 4 hours for adults, 2 hours for children and adolescents ages
9 to 17, or 1 hour for patients under 9. The original order may only be renewed in accordance with these limits for up to a total
of 24 hours. After the original order expires, a physician or licensed independent practitioner (if allowed under state law) must
see and assess the patient before issuing a new order.
In addition to continually monitoring the site of a physical restraint for skin issues, a physical restraint should only be secured to
the bed with a quick-release knot in case of emergency.
View a YouTube video[8] of an instructor demonstration of a tying a quick release knot:

Quick Release Knot

Side Rails
Side rails and enclosed beds may also be considered a restraint, depending on the purpose of the device. Recall the definition of a
restraint as “a device, method, or process that is used for the specific purpose of restricting a patient’s freedom of movement or
access to movement.” If the purpose of raising the side rails is to prevent a patient from voluntarily getting out of bed or attempting
to exit the bed, then use of the side rails would be considered a restraint. On the other hand, if the purpose of raising the side rails is
to prevent the patient from inadvertently falling out of bed, then it is not considered a restraint. If a patient does not have the
[9]
physical capacity to get out of bed, regardless if side rails are raised or not, then the use of side rails is not considered a restraint.
Full side rails are generally only found on beds in acute care. In long-term care, beds usually have a transfer loop that is a much
smaller side rail. The transfer loop allows the resident to support themselves while repositioning in bed and standing up from the
bed. The smaller size of this type of side rail reduces the risk of the resident becoming entrapped and injured from the device. Full
side rails may be ordered by the physician if they allow the resident to reposition independently. If a resident’s bed in a long-term
care setting has full side rails and they are not used for repositioning, they should always be lowered when care is complete, and a
staff member is no longer present in the room. Acute care settings have different regulations regarding full side rails; review
[10]
specific agency policy.

Hand Mitts
A hand mitt is a large, soft glove that covers a confused patient’s hand to prevent them from inadvertently dislodging medical
[11]
equipment such as a catheter, feeding tube, or intravenous (IV) catheter. See Figure 8.23 for an image of a hand mitt. Hand mitts
are considered a restraint by The Joint Commission if they are used under these circumstances:
Pinned or otherwise attached to the bed or bedding
Applied so tightly that the patient’s hands or finger are immobilized
Are so bulky that the patient’s ability to use their hands is significantly reduced
Cannot be easily removed by the patient in the same manner it was applied by staff, considering the patient’s physical condition
and ability to accomplish this objective

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 Figure 8.23 Hand Mitt

[12]
View the following YouTube video for applying hand mitts : Hand Control Mittens With Tie Closure.

Vests
A vest restraint is worn on the upper body and has ties that secure it to a chair or bed frame, allowing the restrained person to sit or
lie in bed.

[13]
View the following YouTube video on properly using a vest restraint : Criss Cross Vest.

Other Restraints
Common items can be considered restraints when used improperly. A general rule is if any device limits the mobility, freedom of
movement, or access to one’s body, it is considered a restraint. The resident must be able to independently remove any device that
is utilized when directed to do so. This action shows that the resident can cognitively and physically control their environment.
Here are some examples of how common devices can be considered a restraint:
Wheelchair brakes that are left on with a resident who cannot independently release them are considered a restraint because it
prevents the resident from moving freely throughout their environment.
Lap trays (used for meals or supporting an immobile limb) are considered a restraint if it impairs the resident’s ability to move.
Self-release seat belts can be used to keep a resident positioned properly in their wheelchair, but the resident must be able to
remove the seat belt if asked to do so.
Gait belts must be removed after residents have completed a transfer. They should not be left on during meals or activities for
convenience because they can cause discomfort.

Restraint Alternatives
There are many interventions available to keep residents safe without applying restraints. When a potentially unsafe behavior is
occurring, the health care team should look at all the factors surrounding the behavior to determine the root cause. After the root
cause is determined, the staff can implement appropriate redirection. Common risks and appropriate interventions include the
following:
If a resident continues to attempt to self-transfer without assistance:
Offer toileting every hour
Offer the opportunity to lie down after meals
Assist in ambulation (if their condition permits) throughout the day
Place a motion alarm in the doorway or near the foot of the bed
Use a pressure or tab alarm in the wheelchair
If a resident is agitated or aggressive towards other residents:
Offer an individual activity such as board games, crafts, or movies

8.7.3 https://med.libretexts.org/@go/page/70394
 Ambulate or take them for a walk in their wheelchair
Give them something to hold such as a stuffed animal
Offer a blanket
Ask about pain, hunger, or toileting needs
If a resident wanders or wants to leave the facility:
Allow them to self-propel in wheelchair in a safe area
Offer an individual activity such as board games, crafts, or movies
Ambulate or take them for a walk in their wheelchair
Apply a wanderguard to the wheelchair or their wrist or ankle
Motion sensors, pressure or tab alarms, and wanderguards are all alarms. There are many facilities that choose not to use alarms
because they can be disruptive to the environment due to the noise and can reduce the dignity of the resident. If implemented
incorrectly, they may not deter the unsafe behavior but merely notify staff the behavior is occurring or has occurred. If an alarm is
indicated in the care plan, the NA is responsible for making sure the alarm is functioning and properly placed as indicated in the
care plan. Behavioral and environmental interventions, as previously discussed, should be considered before alarms are put in
place.
For more information on alarms, view the following YouTube videos:

[14]
Wanderguard : Prevent Wandering With Smart Caregiver Fall Prevention and Anti-Wandering Products
[15]
Pressure alarm : TL-2020 With Corded Bed Pad

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
8. Chippewa Valley Technical College. (2022, December 3). Quick Release Knot. [Video]. YouTube. Video licensed under CC BY
4.0. https://youtu.be/S7LbOclRQcw ↵
9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
10. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
11. “Hand Mitt” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
12. DeRoyal. (2015, May 31). Hand control mittens with tie closure [Video]. YouTube. All rights reserved.
https://youtu.be/7gCp40b9Bcs ↵
13. DeRoyal. (2015, March 31). Criss cross vest [Video]. YouTube. All rights reserved. https://youtu.be/tJ7k8hWzFLI ↵
14. Smart Caregiver. (2017, May 26). Prevent wandering with Smart Caregiver fall prevention and anti-wandering products
[Video]. YouTube. All rights reserved. https://youtu.be/TTMPmg-atPM ↵
15. Smart Caregiver. (2021, June 24). TL-2020 with corded bed pad [Video]. YouTube. All rights reserved.
https://youtu.be/JtsCLkEmQ6A ↵

This page titled 8.7: Restraints and Restraint Alternatives is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra
Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

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8.8: Skills Checklist- Positioning Supine to Lateral (Side-Lying)
1. Gather Supplies: Four pillows
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Position the bed flat.
Raise the bed height.
Raise the side rail on the side of the bed the resident will be facing after repositioning for safety.
Move to the working side of the bed, which is opposite the side rail that was raised.
Explain to the resident that you will move them closer to you before turning on the count of three.
From the working side of the bed using the lift sheet, count to three and move the resident towards you.
Instruct the resident to move their arm closest to the raised side rail away from their body. If able, the resident should grasp
the side rail with the hand closest to you, reaching across their own body.
Raise the resident’s knee that is closest to you to assist in turning.
Explain that you will turn the resident towards the side rail on the count of three.
Count to three and use the lift sheet to turn the resident towards the raised side rail.
Ensure that the resident’s face never comes close to the side rail or becomes covered by the pillow.
Check that the resident is not lying on their bottom arm.
Place a pillow behind the resident’s back, ensuring they will not roll back to the supine position.
Move to the end of the bed and check that the resident is in correct body alignment.
Verify that the resident is in the middle of the bed.
Place a pillow between the resident’s top arm and their rib cage or the bed, ensuring the elbow is not directly on their ribs.
Place a pillow under the top knee, ensuring the knee is not resting directly on the other knee or the ankle is not on top of the
other ankle.
Adjust the pillow under the resident’s head for comfort.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document repositioning and report any abnormal skin findings to the nurse.
View a YouTube video[1] of an instructor demonstration of positioning from the supine to lateral side-lying position:

8.8.1 https://med.libretexts.org/@go/page/70395
 Positioning a Client from the Supine to t…
t…

1. Chippewa Valley Technical College. (2022, December 3). Positioning a Client from the Supine to the Lateral (Side-Lying)
Position. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/kIw9IhPhsBA ↵

This page titled 8.8: Skills Checklist- Positioning Supine to Lateral (Side-Lying) is shared under a CC BY 4.0 license and was authored, remixed,
and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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8.9: Skills Checklist- Transfer From Bed to Chair With a Gait Belt
1. Gather Supplies: Gait belt, wheelchair, and nonskid footwear
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times. Provide for privacy.
Provide for privacy. Explain the procedure to the client.
Explain the procedure to the client.
3. Procedure Steps:
Check the brakes on the bed to ensure they are locked.
Remove the foot pedals from the wheelchair if needed.
Assist the resident to a seated position on the side of the bed with their feet on the floor; allow them to dangle their feet for a
few minutes.
Assist the resident in putting on nonskid footwear.
Place the gait belt on the resident.
Position the wheelchair at the head or foot of the bed so the resident will move towards the wheelchair with the stronger side
of their body. The wheelchair should touch the side of the bed.
Lock the brakes on the wheelchair.
Ask the resident if they feel dizzy or light-headed.
Face the resident and place each of your feet in front of the resident’s feet to prevent them from slipping.
Instruct the resident to push up on the bed to aid in standing on the count of three.
Grasp the gait belt with both hands, with your palms and fingertips pointing up.
Count to three and assist the resident to stand.
Assist the resident to pivot.
Instruct the resident to grasp the arms of the wheelchair when they can feel the back of their knees are in contact with the
wheelchair seat.
Assist the resident to a seated position in the wheelchair.
Remove the gait belt gently to avoid skin injury.
Release the wheelchair brakes.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues, pain with movement, or any other changes noted with the resident.
View a YouTube video[1] of an instructor demonstration of transfer from bed to chair with a gait belt:

8.9.1 https://med.libretexts.org/@go/page/70396
 Transfer From Bed to Chair with a Gait B…
B…

1. Chippewa Valley Technical College. (2022, December 3). Transfer From Bed to Chair With a Gait Belt. [Video]. YouTube.
Video licensed under CC BY 4.0. https://youtu.be/pyoHSHef90c ↵

This page titled 8.9: Skills Checklist- Transfer From Bed to Chair With a Gait Belt is shared under a CC BY 4.0 license and was authored,
remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a
detailed edit history is available upon request.

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8.10: Skills Checklist- Transfer From Bed to Chair With Sit-to-Stand
1. Gather Supplies: Wheelchair, lift, and nonskid footwear. Check agency policy for assistance requirements and the client’s care
plan for current transfer status.
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedural Steps:
Position the wheelchair appropriately, remove the foot pedals, and lock the brakes. Provide ample room to rotate the lift
from the bed to the wheelchair without hitting other objects.
Place the transfer sling under the resident’s armpits with the handles facing away from the resident.
Secure the transfer sling with the seat belt or by crossing the sling straps following manufacturer’s recommendations.
Raise the bed to allow the legs of the lift to go underneath the bed.
Open the legs of the lift if the bed allows room to do so.
Ask the resident to put their feet onto the base of the lift. When bringing the lift closer to the resident, ensure that the arms of
the lift do not hit the resident’s head or arms.
Secure the strap at the base of the lift around the calves of the resident if available.
Check that the resident’s feet are completely on the base.
Place the sling behind the resident’s back and under their armpits on both sides. Secure the sling clasp in front of the patient
around their chest/waist.
Connect the transfer sling to the lift ensuring equal length is attached on each side of the sling.
Instruct the resident to place their hands on the handles of the lift arms.
Check that the sling remains under both of the resident’s armpits and their arms are outside of the lift arms.
Ensure the resident is not experiencing any dizziness before they stand.
Instruct the resident that you will begin raising the lift. Ask them to pull up with their arms and straighten their legs. (If the
resident is not currently able to perform these actions, a sit-to-stand should not be used.)
Use the lift to raise the resident to a standing position.
Slowly move the lift away from the bed. Open the legs of the lift if they are closed underneath the bed.
Slowly move the lift towards the wheelchair.
After the back of the resident’s knees touch the wheelchair seat, explain that you will lower them to the chair. Do not apply
the brakes on the lift because they can cause the resident’s legs to be compressed by the lift as they are lowered to the chair.
While lowering the resident into the wheelchair, assist them to sit all the way back in the wheelchair by guiding the handle
on the sling towards the back of the wheelchair seat.
After the resident is seated in the chair, remove the leg strap and sling from the lift. Instruct the resident to release their
hands from the lift.
Slowly move the lift away from the resident, ensuring the lift does not hit the resident’s head or arms.
Ask the resident to lean slightly forward and remove the sling.
Release the wheelchair brakes.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues, pain with movement, or any other changes noted with the resident.

8.10.1 https://med.libretexts.org/@go/page/70397
View a YouTube video[1] of an instructor demonstration of transfer from bed to chair with a sit to stand:

Transfer from Bed to Chair with a Sit to …

1. Chippewa Valley Technical College. (2022, December 3). Transfer from Bed to Chair with a Sit to Stand. [Video]. YouTube.
Video licensed under CC BY 4.0. https://youtu.be/zs_CIYylxtU ↵

This page titled 8.10: Skills Checklist- Transfer From Bed to Chair With Sit-to-Stand is shared under a CC BY 4.0 license and was authored,
remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a
detailed edit history is available upon request.

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8.11: Skills Checklist- Transfer From Bed to Chair With Mechanical Lift
1. Gather Supplies: Mechanical lift, lift sling, second person to assist, and a wheelchair. Review agency policy for mechanical lifts.
NOTE: The driver of the lift must be at least 18 years old.
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Raise the bed to a working height.
Instruct the resident to cross their arms over their chest to avoid rolling on top of their arm.
Using the lift sheet, roll the resident to one side. Coordinate movement with the resident and the second assistant to avoid
injury.
Position the lift sling underneath the resident from the shoulders to the buttocks. Fan-fold the sling in the middle to allow the
second assistant to pull it through on the other side. The handles should be facing away from the resident.
Ensure the lift sling is on top of the lift sheet.
Inform the resident they will be rolling over the gathered fabric of the sling.
(Second assistant) Using the lift sheet, initiate rolling the resident towards the first assistant with the resident’s arms still
crossed, coordinating movement with the resident and first assistant.
(Second assistant) Pull the lift sling from underneath the resident, smoothing out any wrinkles.
Using the lift sheet, gently roll the resident back to the supine position.
Check that the resident is positioned in the center of the lift sling and their head and knees will be properly supported when
lifted.
Check the body alignment of the resident.
Move the full-body mechanical lift into position over the resident, ensuring the lift does not come into contact with any part
of the resident.
Raise the head of the bed to avoid pulling on the sling when connecting it to the lift.
Hook the top loops of the sling to the lift per manufacturer’s guidelines, ensuring the loops are the same lengths on each
side.
Hook the bottom loops of the sling to lift per manufacturer’s guidelines, ensuring the loops are the same lengths on each
side.
Position the wheelchair appropriately and lock the brakes. Provide ample room to rotate the lift from the bed to the
wheelchair without hitting other objects.
Recline the wheelchair slightly if able.
Instruct the resident to cross their arms over their chest.
Prepare to support the resident’s feet by having the second assistant move to the same side of the bed as the driver and the
lift.
Inform the resident you will be raising the lift and moving them to the wheelchair.
Raise the lift until the resident is no longer in contact with the bed while the second assistant guides the resident’s feet.
Position the resident over the wheelchair with the main support of the lift to one side, thus avoiding the resident’s feet
coming into contact with the lift support.
After the driver of the lift moves behind the wheelchair, have the resident grasp the handles on the lift sling.
Instruct the resident you will be lowering the lift sling.
(Second assistant) Lower the lift while the driver gently pulls up on the sling to get the resident’s back positioned upright
and against the back of the wheelchair.
(Second assistant) Guide the resident’s feet to keep their body aligned and avoid coming in contact with the left.
Remove the sling from the lift after the resident is properly seated.

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 Carefully move the lift away from the resident, avoiding the resident’s head and limbs from coming into contact with the
lift.
Tuck the lift sling into the wheelchair, keeping the fabric smooth to avoid skin issues and keeping loops away from any
moving parts of the wheelchair.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues, pain with movement, or any other changes noted with the resident.
View a YouTube video[1] of an instructor demonstration of transfer from bed to chair with a mechanical lift:

Transfer from Bed to Chair with a Mech…

Mech…

1. Chippewa Valley Technical College. (2022, December 3). Transfer from Bed to Chair with a Mechanical Lift. [Video].
YouTube. Video licensed under CC BY 4.0. https://youtu.be/sqkE7MNndyE ↵

This page titled 8.11: Skills Checklist- Transfer From Bed to Chair With Mechanical Lift is shared under a CC BY 4.0 license and was authored,
remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a
detailed edit history is available upon request.

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8.12: Skills Checklist- Ambulation From Wheelchair
1. Gather Supplies: Gait belt, wheelchair, nonskid footwear, and assistive devices if needed (walker or cane)
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times. Provide for privacy.
Provide for privacy. Explain the procedure to the client.
Explain the procedure to the client.
3. Procedure Steps:
Check the brakes on the wheelchair to ensure they are locked.
Verify the resident is wearing nonskid footwear.
Properly place the gait belt around the resident’s waist.
Check the gait belt for tightness by slipping your fingers between the gait belt and the resident.
Ask the resident if they feel dizzy or light-headed.
Face the resident and place each of your feet in front of the resident’s feet to prevent them from slipping.
Instruct the resident to push up on the wheelchair arms on the count of three to assist with standing.
Count to three and assist the resident to a standing position.
Provide the resident’s assistive device, as needed.
Move to the weak side of the resident, slightly behind them. Hold the gait belt with your palms and fingertips pointing
upwards.
Stabilize the resident as they ambulate for the desired duration.
Assist the resident to pivot/turn in front of the wheelchair.
Ensure the wheelchair brakes are locked.
Instruct the resident to grasp the arms of the wheelchair when the back of their knees touch the wheelchair seat.
Assist the resident to a seated position in the wheelchair.
Remove the gait belt.
Release the wheelchair brakes.
4. Post-Procedure Steps:
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report any skin issues, pain with movement, or any other changes noted with the resident.
View a YouTube video[1] of an instructor demonstration of ambulation from a wheelchair:

8.12.1 https://med.libretexts.org/@go/page/70399
 Ambulation From a Wheelchair

1. Chippewa Valley Technical College. (2022, December 3). Ambulation From a Wheelchair. [Video]. YouTube. Video licensed
under CC BY 4.0. https://youtu.be/jtj95sPrc_k ↵

This page titled 8.12: Skills Checklist- Ambulation From Wheelchair is shared under a CC BY 4.0 license and was authored, remixed, and/or
curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history
is available upon request.

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8.13: Learning Activities

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8.14: VIII Glossary
Ambulation: A medical term used for walking.
Bariatric lifts: Mechanical lifts that support a client weighing 600 or more pounds.
Body alignment: Good posture principles that prevent musculoskeletal injuries.
Bony prominences: Areas of the body where a bone lies close to the skin’s surface, such as the back of the head, shoulders,
elbows, heels, ankles, tops of the toes, hips, and coccyx.
Chemical restraint: A drug used to manage a patient’s behavior, restrict the patient’s freedom of movement, or impair the patient’s
ability to appropriately interact with their surroundings, that is not standard treatment or dosage for the patient’s condition.
Coccyx: Tailbone.
Dangle: Sitting up on the edge of bed for a few minutes before standing to prevent orthostatic hypotension and dizziness.
Foam boots: Specialized soft boots used to support the ankles and keep the heels floated off the bed.
Foot cradle: A device used to keep the sheets and blankets off the tops of a client’s toes.
Fowler’s position: A position where the client is lying on their back with their head elevated between 30 and 90 degrees.
Friction: Injury caused to skin when it is rubbed by clothing, linens, or another body part.
Hand mitt: A large, soft glove that covers a confused patient’s hand to prevent them from inadvertently dislodging medical
equipment such as a catheter, feeding tube, or intravenous (IV) catheter.
Immobility: The loss of independent control of one’s body to change positions and function safety within the environment.
Lateral (side-lying) position: A position that places the client on their left or right side to relieve pressure on the coccyx or
increase blood flow to the fetus in pregnant women.
Mobility: The ability to move one’s body parts, change positions, and function safely within the environment. It is one of the most
important factors for remaining independent.
Orthostatic hypotension: A sudden drop in blood pressure that can cause clients to feel dizzy and increase their risk for falls.
Orthotic: A support, brace, or splint used to support, align, prevent, or correct the function of movable parts of the body.
Physical therapists: Health specialists who evaluate and treat movement disorders.
Pressure injuries: Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense
and prolonged pressure and/or shear.
Prone position: A position where the client is placed on their stomach with their head turned to one side.
Prosthetics: An addition or attachment to the body that replicates the function of a lost or dysfunctional limb.
Restraints: Devices used in health care settings to prevent patients from causing harm to themselves or others when alternative
interventions are not effective.
Seclusion: The confinement of a patient in a locked room from which they cannot exit on their own. It is generally used as a
method of discipline, convenience, or coercion.
Shear: Injury to skin that occurs when skin moves one way, but the underlying bone and muscle stay fixed or move the opposite
direction.
Sims’ position: A position similar to the lateral position, but the client is always placed on their left side and their left arm is
placed behind their body.
Skin tear: A separation of skin layers caused by shear, friction, and/or blunt force.
Supine position: A position where the client is lying flat on their back.
Transfer status: How a resident moves from one place to the other, such as from a bed to wheelchair or a wheelchair to toilet.
Transfer status orders: Orders that establish how much assistance is required for moving a client based on how much body
weight they can independently bear and how much weight an assistant is required to support. Transfer status orders include

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independent, contact-guard-assist (CGA), 1 assist (1A), 2 assist (2A), sit-to-stand lift, or full-body mechanical lift.
Vertigo: A sensation that the room is spinning.

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 CHAPTER OVERVIEW

9: Promote Independence Through Rehabilitation/Restorative Care

9.1: Introduction to Promote Independence Through Rehabilitation/Restorative Care
9.2: The Rehabilitation Process
9.3: Members of the Therapy Team
9.4: Complications of Immobility
9.5: Rehabilitation Versus Restorative Care
9.6: Promoting Independence During ADLs
9.7: Assisting With Sensory Deficits
9.8: Fall Prevention
9.9: Skills Checklist- Range of Motion (ROM) Exercises for the Shoulder
9.10: Skills Checklist- Range of Motion (ROM) for the Hip and Knee
9.11: Skills Checklist- Application of Compression Stockings (TED Hose)
9.12: Learning Activities
9.13: IX Glossary

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1
9.1: Introduction to Promote Independence Through Rehabilitation/Restorative Care
Learning Objectives
Assist client with range of motion exercises
Promote client independence during activities of daily living (ADL)
Assist clients with hearing or vision impairment with activities of daily living
Assist clients with speech impairment with activities of daily living
Assist with restorative therapies

Chapter 8 discussed how nursing assistants help clients with mobility with actions ranging from repositioning them in bed,
transferring them out of bed to a chair, or ambulating them in the hallway. This chapter will focus on how the nursing assistant
promotes client functioning and independence through rehabilitation and restorative care.
Acute health events and chronic illnesses can reduce a client’s level of functioning and independence. For example, clients who
experience a stroke or hip fracture or live with chronic disease like heart failure or chronic obstructive pulmonary disorder (COPD)
often require assistance in completing their activities of daily living (ADLs). Any condition that requires bed rest can cause muscle
atrophy, decreased lung function, and other complications. Clients recovering from illnesses or injury may require therapy
performed by the licensed therapy team to return lost levels of function. As their functioning is restored, the nursing assistant can
help clients retain the highest possible level of functioning and independence and promote their physical and mental well-being.

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9.2: The Rehabilitation Process
After an individual experiences an acute illness, injury, or significant change in health status, there is always a period of recovery.
During recovery, some individuals participate in rehabilitation. Rehabilitation helps people regain body functions they lost due to
medical conditions or injury. Rehabilitation can help improve many body functions, including bowel and bladder problems,
[1]
chewing and swallowing, problems thinking or reasoning, movement or mobility, speech, and language.
The goal of the rehabilitation is to return the person to their prior level of function before the health event. The length of time for
recovery varies for each individual, and there are several factors that can influence its progression. A list of factors that can affect
an individual’s recovery process include the following:
Comorbidities: Comorbidities are coexisting health conditions. Having another chronic diagnosis or other acute condition may
slow the progression of healing. Here are some examples of how comorbidities affect healing and recovery:
If a person has diabetes, their healing process is slower, and their risk of infection is higher.
If a person has chronic respiratory or cardiac conditions such as asthma, chronic obstructive pulmonary disease (COPD), or
heart failure, their endurance to complete rehabilitation exercises may be decreased.
If a person has dementia, they may not remember they are injured and may try to move without assistance, resulting in a fall
or further injury to the affected area.

Age: As people age, healing slows down, and the functioning of various body systems declines. Older adults are more likely to
have comorbidities and complications related to these coexisting conditions that can slow or even halt the rehabilitation process.
Motivation: If a person lives with severe chronic illness or experienced health events that previously required rehabilitation,
they may feel like giving up or not putting in the effort to return to their prior level of functioning. Some people prefer someone
assisting them with their ADLs for a variety of reasons, such as experiencing increased pain with movement, severe fatigue, or
feeling lonely and desiring increased interaction with others.
Resources: Resources include support from family members or friends who offer encouragement, nearby health care providers
in the community, and transportation available to get to appointments. Insurance also plays a role in recovery because the
amount of reimbursement for rehabilitation services is determined by insurance coverage.
The types of therapy provided are determined by the individual’s illness or injury. The roles and responsibilities of different
disciplines will be further discussed in the “Members of the Therapy Team” section of this chapter. Rehabilitation may begin in an
acute care setting when intensive interventions are required several times throughout the day and then transfer to a short-term stay
or rehabilitation unit in a long-term care facility for further rehabilitation. In the long-term care facility, they typically see therapists
once or twice a day until they are independent enough to return to their previous home environment. Both of these situations are
referred to as in-patient therapy because the rehabilitation treatment occurs in a facility where the client is staying. However, in
some cases, the individual can return home and visit a therapist once or twice a week, which is referred to as out-patient therapy.
Out-patient therapy is commonly prescribed for post-operative rehabilitation, such as that required for a hip, knee, or shoulder
replacement.
Therapists determine the types of interventions needed and the frequency of treatments based on each individual’s situation.
Therapists provide rehabilitation treatment for as long as the client continues to improve, but it will conclude when their progress
plateaus (i.e., their level of function remains the same and no longer improves). Sometimes an individual is unable to achieve their
prior level of functioning and must remain in a long-term care facility for assistance and supportive care for the remainder of their
life. When this occurs, the individual will have a restorative care plan that is further discussed in the “Rehabilitation Versus
Restorative Care” section of this chapter.

1. A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2022. Physical medicine and rehabilitation;
[updated 2022, April 1]. https://medlineplus.gov/ency/article/007448.htm ↵

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9.3: Members of the Therapy Team
In a short-term stay unit of a long-term care facility, there is typically a therapy gym where rehabilitation interventions are
performed. Therapists may be employees of the facility or may work for another health care organization that contracts with the
long-term care facility to provide therapy to its residents.
The therapy team is part of the interprofessional health care team as previously discussed in Chapter 2.3, “Members of the Health
Care Team and Nursing Home Structure.” It is helpful to understand the roles and responsibilities of each type of therapy
discipline, especially if you work on a short-term stay or rehabilitation unit. Occupational therapists, speech therapists, and physical
therapists are the most common types of therapists. Respiratory therapists may be present in long-term care settings that have
specialized ventilator units.
Occupational Therapists (OT): Occupational therapists assess, plan, implement, and evaluate interventions to help clients achieve
their highest possible level of independence in completing their activities of daily living (ADLs) such as bathing, grooming, eating,
and dressing. OTs also teach clients how to use adaptive devices to complete their ADLs. Adaptive devices include long shoehorns
(to assist clients with putting shoes on), sock pulls (to independently pull on socks), adaptive silverware (to facilitate independent
eating), grabbers (to pick items up from the floor), and special devices to manipulate buttoning so the client can dress and button
their clothing independently. These devices are further discussed in the “Promoting Independence During ADLs” section. OTs may
also assess the client’s home for safety and their need for assistive devices when they return home (if they are able to do so). For
example, OTs may recommend home environment modifications such as ramps, grab rails, and handrails to ensure client safety and
[1]
independence.
Physical Therapists (PT): Physical therapists are licensed health care professionals who assess, plan, implement, and evaluate
interventions related to clients’ functional abilities in terms of their strength, mobility, balance, gait, coordination, and joint range
of motion. They supervise exercises tailored for a client’s condition and teach them how to use assistive devices like walkers and
[2]
canes.
Speech Therapists (ST): Speech therapists assess, diagnose, and treat communication and swallowing disorders. For example,
clients with expressive aphasia understand what other people say but struggle to get words out, speak in very short sentences, and
omit words. They may say, “Want food,” or “Bathroom go.” Speech therapists teach these clients how to use word boards and other
electronic devices to facilitate communication. STs also assess clients with swallowing disorders (i.e., dysphagia) and determine if
they require thickened liquids or a modified diet to prevent aspiration of substances into their lungs. STs collaborate with other
[3]
members of the health care team, including nurses, dieticians, and health care providers.
Respiratory Therapists (RT): Respiratory therapists treat respiratory-related conditions in patients. Their specialized respiratory
care includes managing oxygen therapy; drawing arterial blood gasses; managing patients on specialized oxygenation devices such
as mechanical ventilators, CPAP, and Bi-PAP machines; administering respiratory medications like inhalers and nebulizers;
intubating patients; assisting with bronchoscopy and other respiratory-related diagnostic tests; performing pulmonary hygiene
measures like chest physiotherapy; and serving an integral role in maintaining a client’s airway during cardiac and respiratory
[4]
arrests.

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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request.

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9.4: Complications of Immobility
Movement, activity, and mobility positively affect one’s overall health. When someone is recovering from a severe illness or injury, their mobility is often reduced, and they may be unable to
perform ADLs. Health care team members play a vital role in preventing the physical and mental decline in functioning that can occur from immobility by proactively implementing interventions.
Risks of immobility are well-known, and complications are viewed as avoidable. In fact, many insurance companies do not reimburse health care agencies for complications resulting from
immobility, like pressure injuries, because they are viewed as avoidable with the proper care. Therefore, nursing assistants must be diligent in their actions and observations to maintain their client’s
health and prevent complications.
See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. Promoting clients’ independence in
completing their ADLs and encouraging activity as tolerated can help prevent all these complications of immobility. “Encouraging activity as tolerated” means involving the resident in movement
while also adhering to mobility restrictions noted in the care plan and observing for respiratory changes that indicate the resident may be lacking endurance to maintain the activity. Sometimes a
client’s lack of endurance in completing activities requires the nursing assistant to segment their ADLs. Segmenting ADLs refers to breaking up tasks to accommodate the client’s activity
intolerance. An example of segmenting ADLs would be assisting a person to bathe in bed as independently as possible, letting them rest after bathing, and then returning later to assist them with
dressing and grooming to get them ready for the day.
Table 9.4 Potential Complications of Immobility and Preventative Measures

Body System Potential Complication(s) Preventative Measures

Repositioning every 1-2 hours

Ensuring proper hygiene
Integumentary (Skin) Pressure Injuries Providing incontinence care as needed
Providing skin care
Encouraging good nutrition

Muscle atrophy Assisting with active or passive range of motion (ROM) exercises
Musculoskeletal
Contracture Applying splints or positioning devices as prescribed

Encouraging fluids (if not contraindicated)

Encouraging fiber intake
Constipation
Digestive Encouraging activity as tolerated
Incontinence
Providing frequent toileting
Providing bowel and bladder retraining if needed

Encouraging incentive spirometry or coughing and deep breathing

Respiratory Decreased lung function
Encouraging activity as tolerated

Ambulating
Applying compression stockings or other compression devices as
Deep vein thrombosis (DVT)
ordered
Circulatory Decreased cardiac function
Encouraging low sodium intake (as prescribed)
Increased fluid retention
Obtaining accurate daily weights
Elevating extremities

Involving clients in social activities

Offering pleasurable individual activities if not interested in group
Psychological Depression activities
Encouraging visits by family, friends, or volunteers for 1:1
interaction

Devices to Prevent Contracture

The “Applying Prosthetics and Orthotics” section in Chapter 8 describes devices such as a foot split to prevent musculoskeletal contracture. There are additional devices that can prevent a client’s
hand contracture, as well as prevent their fingernails from creating open skin areas in their palm. The first type of hand device is a cone that slides into the palm of the hand and is kept in place with
a soft elastic band. The cone should not be forced into the fingers but placed gently. A second type of device is a palm protector that is softer than the cone and separates the fingers from one
[1] [2]
another. If neither of these devices is available, a washcloth can be rolled and placed underneath the fingers. See Figure 9.1 for an image of a cone and palm protector, and Figure 9.2 for images
showing application of these devices.

Figure 9.1 Cone to Prevent Hand Contracture (left) and a Palm Protector (right)

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 Figure 9.2 a.) Cone on Client’s Hand, b.) Palm Protector Viewed on the Palm of a Client’s Hand, and c.) Palm Protector Viewed on the Dorsal Side of Client’s Hand

Range of Motion (ROM)

Active and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. ROM exercises facilitate movement of specific joints and promote mobility
of the extremities. Because changes in joints can occur after just three days of immobility, ROM exercises should be started by the nursing assistant as soon as they are directed by the nurse as safe
to do so.
There are three types of ROM exercises: passive, active, and active assist. Passive range of motion is movement applied to an individual’s joint by another person or by a passive motion machine.
When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part. For example, clients who undergo knee
[3]
replacement surgery may be prescribed a passive range of motion machine that continuously flexes and extends the patient’s knee while they are lying in bed. See Figure 9.3 for an image of a
passive motion machine.
Active range of motion is movement of a joint by the individual with no outside force aiding in the movement. A staff member may provide verbal cues to complete the action, but the movement is
done independently by the client.
Active assist range of motion is joint movement by an individual with partial assistance from an outside force. For example, during the recovery period after shoulder surgery, a client attends
physical therapy and receives 50% assistance in moving their arm with the help of a physical therapy assistant.

Figure 9.3 Passive Motion Machine

Several terms are used to refer to certain body movements during range of motion exercises, such as abduction, adduction, flexion, and extension. Abduction refers to the movement of a limb away
from the body’s midline. For example, hip abduction is the movement of the leg away from the midline of the body. We use this action every day when we step to the side, get out of bed, and get out
of the car. Adduction refers to moving a limb towards the midline. For example, if a person has their fingers spread wide apart, bringing them back together is adduction. Flexion is movement that
decreases the angle between two bones and extension is movement that increases the angle between two bones. For example, a bicep curl during weight lifting demonstrates both flexion and
extension. Flexion occurs when the bicep muscle contracts and the elbow joint bends, lifting the weight. Extension occurs when the arm is straightened back to starting position, increasing the angle
between the elbow joint.
When assisting a client with ROM activities, the nursing assistant must follow the plan of care established by the licensed therapist. The plan is tailored to the needs of the individual and will
include the specific joints to move. Typically, larger joints such as shoulders, elbows, hips, knees, and ankles are included in ROM exercises, but ROM can be also applied to smaller joints such as
the fingers and wrists.
When assisting with ROM exercises, the nursing assistant must support any joints below the joint being exercised to prevent injury. For instance, if the shoulder is being exercised, the nursing
assistant places their hands underneath the elbow and wrist to support them. The joint should be moved gently and only to the point to where there is slight resistance. A joint should never be forced
to achieve full ROM if there is resistance. For example, a client who has had limited mobility for several years may have a joint that can only be moved a few inches, but it is important to maintain
that mobility, no matter how small.
While providing ROM, the nursing assistant must observe for objective and subjective signs of pain. The resident should be asked if they are experiencing any pain during the movement, and the
assistant should watch for nonverbal signs of pain like grimacing, clenching the teeth, groaning, or labored breathing. Refer to the “Objective and Subjective Signs of Pain” subsection in Chapter 6.3
to review observations to make and report. See the steps for providing ROM for the shoulder and hip joints in the “ROM Exercises for the Shoulder” and “ROM Exercises for the Hip and Knee”
Skills Checklists later in this chapter.

Incentive Spirometry
When a client experiences immobility, normally healthy alveoli can collapse and cause decreased lung function. Decreased lung function can reduce a person’s stamina and their ability to perform
activities, referred to as activity intolerance. To prevent a decrease in lung function, reduce the build-up of fluids in the airways, and prevent pneumonia, clients are often prescribed incentive
[4]
spirometry to keep their bronchioles open. The incentive spirometer encourages a client to complete slow, deep breathing to keep their bronchioles open. See Figure 9.4 for an image of a client
using an incentive spirometer. Nursing assistants are often expected to encourage clients to use their incentive spirometer hourly.

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 Figure 9.4 Using an Incentive Spirometer
The nurse or respiratory therapist initially teaches the client how to use the incentive spirometer but encouraging and observing clients complete this action every hour is commonly delegated to a
nursing assistant. The client should sit upright (if possible), place the mouthpiece in their mouth, and create a tight seal with their lips around it. They should breathe in slowly and as deeply as
possible through the tubing, with the goal of raising the piston to their prescribed level. The resistance indicator on the right side should be monitored to ensure they are not breathing in too quickly.
The client should attempt to hold their breath for as long as possible (at least five seconds) and then exhale and rest for a few seconds. Coughing is expected, and clients should be encouraged to
expel any mucus (not swallow it). This technique should be repeated by the client ten times every hour while they are awake. Report completion of the activity to the nurse who documents
[5]
frequency and effectiveness of this intervention.

Compression Stockings
Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. When blood is not moving much due to client inactivity, it can coagulate (i.e, form a clot). This
blockage reduces blood flow to the affected area. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the
cardiovascular system. If the clot breaks free, it can travel to the lungs and become fatal.
The best way for nursing assistants to prevent DVT is to assist clients to ambulate or otherwise complete as much activity as they can tolerate. Some clients are prescribed compression stockings,
also referred to as thrombo-embolic-deterrent hose (TED hose). Compression stockings promote the return of fluid back into circulation by gently providing pressure on veins. They are commonly
used for clients with swelling of their extremities (edema) caused by cardiac conditions that cause fluid retention.
Compression stockings require a physician’s order and should be applied in the morning and taken off at night. They should be applied upon awakening because edema is usually at its lowest point
after lying in bed overnight. However, as the client sits or stands upright during the day, blood tends to pool in the lower legs. The pressure from compression stockings helps return fluid into the
cardiovascular system and may reduce the risk for DVT.
When removed at night, the compression stockings should be washed by hand in the sink with soap and water and then hung to air dry. Do not send them to the laundry or put them on a heater to
dry because this can cause shrinking and ruin the hose. Clients often have two or more pairs of compression stockings to ensure they dry completely before wearing them again in the morning.
[6]
Compression stockings may be knee length or hip length. See Figure 9.5 for an image comparing both lengths. The amount of pressure the hose applies to the legs is prescribed. For example, some
compression stockings may seem like slightly tight socks, whereas other stockings for clients with severe edema are custom-made to fit very tightly and may have a zipper for ease of application.

Figure 9.5 Thigh-high TED Hose (left) and Knee-

high TED Hose (right)
When applying stockings, proper placement on the heel is important. The stockings have a square marker around the heel to guide correct placement on the heel. It can be difficult to see this square
[7]
but stretching the fabric around the heel area should make it more visible. See Figure 9.6 for an image of locating the heel marker. If there is writing on the stocking, it should be on the outside and
facing away from the skin when worn.

Figure 9.6 Locating the Heel Marker on TED Hose

When applying TED hose, find the heel marker first. You can gather or roll the sides of the hose down to the heel or choose to turn the stocking inside out to the heel marker. If turned inside out, put
[8]
your hand inside the hose, hold at the top of the heel marker with your thumb and forefinger, and then pull the top of the stocking down to the heel marker. See Figure 9.7 for a demonstration of
[9]
these techniques. Use any of these techniques to place the stocking on the heel, and then check for proper placement of the heel marker before applying the rest of the stocking. See Figure 9.8 for
heel placement.

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 Figure 9.7 TED Hose Gathered (left), Rolled (center), and Turned Inside
Out (right) to Place on Client’s Heel

Figure 9.8 Ensure Proper Placement of Heel

Marker on Heel
After the heel of the stocking is placed properly on the client’s heel, check that the hose is not twisted. Make any adjustments before proceeding because the hose will be very difficult to adjust after
it is pulled up the leg. When you have the hose positioned correctly, pull the remainder of the stocking up to the knee or hip, depending upon the length of the hose. Check that there are no wrinkles
in the hose and that the client has no discomfort.
The toe of the stocking is typically open to allow for easy assessment of the client’s circulation. The fabric should be completely over the toes, or completely at the base of the toes, to prevent skin
[10]
breakdown or blockage of circulation to the toes. See Figure 9.9 for images of both types of applications of the toe opening of the stocking.

Figure 9.9 a.) and b.) TED Hose Covering Toes and c.) TED Hose at the Base of the Toes
Regular socks or slippers can be placed over the TEDs for warmth if desired. For specific steps in applying TED hose, see the “Application of Compression Stockings (TED Hose)” Skills Checklist
at the end of the chapter.

1. “Cone to Prevent Hand Contracture (left) and a Palm Protector (right)” by Myra Reuter for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵
2. “Cone and Palm Protectors on Client" by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
3. “Continuous_Passive_Motion_Machine.jpg” by User:Ravedave is licensed under CC BY-SA 3.0 ↵
4. “Incentive Spirometer.png” by BruceBlaus is licensed under CC BY-SA 4.0 ↵
5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
6. “TED Hose Lengths.jpg" by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
7. “TED Hose Heel Marker.jpg" by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
8. “TED Hose Application Methods.jpg" by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
9. “Heel Marker on TED Hose.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
10. “Toes of TED Hose.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵

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9.5: Rehabilitation Versus Restorative Care
As previously explained in “The Rehabilitation Process” section, speech therapists, occupational therapists, and physical therapists
create the client’s rehabilitation plan with the goal of returning them to their level of function prior to the injury or illness. When an
individual has progressed to their highest level of functioning, a restorative care plan is established to ensure this level of function
is maintained. Although therapists provide rehabilitation therapy, nursing assistants are responsible for providing restorative care
planned by the therapy team.
Common restorative plans include assisting with ambulation (Chapter 8.5); performing passive or active range-of-motion (ROM)
exercises (Chapter 9.6); assisting with activities of daily living (ADLs) (Chapter 5.2); and applying prosthetics, splints, and
orthotics (Chapter 8.6). Providing restorative care should be documented because it is an integral part of keeping residents as
independent as possible and maintaining their overall health and quality of life. If the client resides in a facility that receives
Medicare reimbursement, restorative care is reported as part of the person’s quarterly minimum data set (MDS) assessment. (To
review aspects of MDS, see Chapter 1.5, “Documenting and Reporting.”) If it is found that a resident experienced a decline in
mobility because their restorative care plan was not being followed appropriately, the facility must provide therapy at no charge to
restore their prior level of function.
Restorative care can occur individually or within a group. An individual activity means the nursing assistant is working with one
resident at a time on that resident’s specific restorative needs. Restorative care can also occur in a group setting, such as an exercise
group where residents follow the lead of an aide and participate as they are able. As discussed in the Chapter 8.6, “Applying
Prosthetics and Orthotics” section, it is the nursing assistant’s responsibility to know how to properly perform restorative care, as
well as keep residents safe from injury during restorative activities. If you are unsure about any aspect of restorative care, seek
instruction from your supervising nurse.
Although clients benefit from restorative care and are encouraged to participate, they do have the right to refuse to participate in
restorative care, just as they do in any other aspect of their health care. Certain situations, such as those described below, can make
[1]
it difficult to motivate residents to participate in restorative care :
The resident has cognitive deficits that make the benefits of restorative care difficult to understand or impair their ability to
participate.
The resident has been dependent on others for their daily care for a long time.
The resident experiences pain associated with the activity.
The resident (or their caregiver) is fearful of falling or becoming injured when performing the activity.
There is unfamiliarity or the lack of a trusting relationship between the caregiver and resident.
If these circumstances occur, the nursing assistant should continue to encourage the resident to participate in the restorative care in
a respectful manner. It may be helpful to delay the care and reapproach the resident at a different time of day. If the resident
displays any subjective or objective signs of pain, it should be reported to the nurse for assessment and treatment. Involving loved
ones in explaining the importance of restorative care can also enhance a resident’s participation, along with reassurance from a
nurse or therapist who oversees the restorative plan. If the resident continues to decline participation despite these attempted
approaches, the nursing assistant should report the situation to the nurse, as well as document it was the resident’s choice to not
participate in restorative care activities despite the approaches attempted.

For more information on restorative care, see Restorative Care’s Effect on Activities of Daily Living Dependency in Long-stay
Nursing Home Residents.

1. Talley, K. M., Wyman, J. F., Savik, K., Kane, R. L., Mueller, C., & Zhao, H. (2015). Restorative care's effect on activities of
daily living dependency in long-stay nursing home residents. The Gerontologist, 55(Supplement 1), S88–S98.
https://doi.org/10.1093/geront/gnv011 ↵

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upon request.

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9.6: Promoting Independence During ADLs
As a health care professional, it is your responsibility to maintain residents’ optimal levels of functioning by encouraging their
participation and independence in completing activities of daily living (ADLs). While it may be quicker and more efficient to
wheel someone to the dining room rather than assisting them to walk there, it is detrimental to their health to do so. As previously
discussed in the “Complications of Immobility” section of this chapter, many interventions prevent decline in residents’
functioning, including encouraging activity as tolerated, and promote independence in completing ADLs with segmenting as
needed. Independence in completing ADLs not only prevents complications of immobility but also enhances their quality of life by
promoting mental wellness through enhancement of their autonomy and self-esteem.
However, some clients may prefer others to completely care for them because the movements are painful or involve more effort
than they are willing to exert. As you gain more experience as a nursing assistant, you will learn to find the delicate balance
between promoting health and following client preferences.
Always encourage clients to complete as many ADLs as they can, segmenting them if needed. When you notice a client is
becoming fatigued or irritable when performing a task, it is often a good time to begin assisting the client. It does not matter how
little a person is able to do for themselves; they should be given the time and opportunity to do so. For nonverbal clients, consider
using a white board, communication book, or other device to assist in their communication. These actions demonstrate respect for
the person’s dignity, as well as promote their physical health and cognitive involvement in their own care. Refer to the Chapter 8.3,
“Promoting Joint Mobility and Activity” section for other ways to encourage mobility and independence.
The therapy team will assess the client and recommend aids that can promote independence to complete daily tasks. Common aids
for ADLs may include a reacher, sock aid, bath sponge, and an elongated shoehorn. All these tools allow a person to reach objects
or complete hygiene needs with less bending or stretching. They may be used temporarily during the rehabilitation process until
[1]
full ROM is achieved, especially after joint replacement surgeries. See Figure 9.10 for an image of these assistive devices.

Figure 9.10 Reacher, Sock Aid, Elongated Shoehorn, and Elongated Bath
Sponge (top to bottom).

Sock Aid
To utilize the sock aid, the sock is placed around the plastic mold. The person holds the rope handles and then puts their foot into
[2]
the sock. They pull on the ropes to get the sock completely on the foot without bending over to the floor. See Figure 9.11 for an
[3]
image of the placement of a sock on a sock aid and Figure 9.12 for an image of getting the sock on the foot.

Figure 9.11 Placing a Sock on the Sock Aid

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 Figure 9.12 Putting a Sock on the Foot Using a Sock Aid
Please also review assistive devices to promote independence with feeding in “Assistance With Nutrition and Fluid Needs.”

1. “ADL Aids” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
2. “Sock Aid.jpg" by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
3. “Applying Sock Aid.png” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵

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9.7: Assisting With Sensory Deficits
An impairment of one or more senses can occur in clients of any age, in addition to the aging process causing a decline in all sensory
functioning. Sensory impairments, especially vision and hearing impairments, can impact the way a person navigates through the environment
and thus increases their risk for falls. Refer to Chapter 11.8, “Neurological System” for additional information about sensory impairments.
Information regarding communicating with individuals affected by sensory deficits can be found in the Chapter 1.3, “Strategies for
Communicating With Patients With Impaired Hearing, Vision, and Speech” subsection. Interventions that can be performed by nursing assistants
to reduce safety risks are described below.

Visual Impairment
The human eye changes around age 40 and decreases an individual’s ability to see close-up objects clearly and makes reading more difficult,
although distance vision remains intact. Depth perception also becomes distorted, meaning the person cannot accurately determine the distance
between themselves and another object.
Other eye conditions may occur with age that impair vision. Some people develop cataracts, a clouding of the clear lens of the eye. Cataracts
[1]
can be observed in a person’s eye by the appearance of a cloudiness in their pupil. See Figure 9.13 for a simulated image of a person with
cataracts.

Figure 9.13 Simulated Image of a Cataract

Glaucoma is a visual condition caused by elevated pressure on the optic nerve, resulting in loss of peripheral vision, blind spots, or even
blindness across the entire visual field.
Macular degeneration is another visual condition that results in a blind spot in an individual’s center field of vision. It is the leading cause of
[2]
vision loss in people over 50. See Figure 9.14 for a simulated image of what a person with macular degeneration may experience.

Figure 9.14 Simulated Vision of a Person With Macular Degeneration

[3] [4]
The Snellen chart is a common tool for assessing distant vision. See Figure 9.15 for a simulated image of how a person with 20/20 vision
sees the Snellen chart compared to simulated visual experiences of those with levels of low vision and blindness.

Figure 9.15 Simulated Views of the Snellen Chart With 20/20 Vision Compared to
Levels of Impaired Vision

To learn more about cataracts, visit the MedlinePlus webpage on cataracts.

[5]

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 [5]
To experience what someone with cataracts may see, watch the following YouTube video : See What I See: Cataracts.
To learn more about glaucoma, visit the National Eye Institute web page on glaucoma.
[6]
To experience what someone with glaucoma may see, watch the following YouTube video : Glaucoma Simulation – Busy Road.
To learn more about macular degeneration, visit the American Academy of Ophthalmology’s What is Macular Degeneration? web page.
[7]
To experience what someone with macular degeneration may see, watch the following YouTube video : See What I See: AMD.

The simplest interventions for maintaining safety for clients with visual impairment include ensuring they are wearing their prescribed
eyeglasses, the glasses are clean, and their living areas are well-lit. There should be no clutter, area rugs, or other small objects on the floor or in
a direct path to the bathroom, closet, or exit door of the room to prevent tripping. Keeping the room and personal belongings arranged in a
consistent manner allows residents to remain aware of the room set-up, making it easier for them to navigate despite impaired vision. If their
visual impairment is severe, tell them where personal items are located before leaving the room, especially the call light and frequently used
things like facial tissue, beverages, television remotes, or phones. When ambulating a resident with poor vision, tell them when they are getting
close to an object that could pose a fall risk.

Hearing Loss
The most common form of hearing loss occurs as a natural part of aging and is called presbycusis. This type of hearing loss is typically worse at
higher frequency sounds, so it interferes with speech recognition and music appreciation. Men tend to experience greater hearing loss than
females, perhaps because they have historically worked in louder environments, but it is unknown how much the differences in hearing between
[8]
genders are caused by biological or social factors.
Hearing can impact an individual’s safety risks. For example, the sense of hearing allows a person to locate objects around them making noise
without much conscious thought. For example, sounds like fire alarms or ambulance sirens warn people of emergencies. To understand how
sound affects safety, try wearing noise-canceling headphones or earplugs while seated in a populated, busy area. Notice how the lack of hearing
changes your perception of movement and the location of objects in your environment.
To assist individuals with hearing loss, use other senses, such as vision and touch, to aid in communication. Stand directly in front of the person
when you are speaking, use appropriate gestures to guide actions, and use a light touch to gain their attention or assist in movement. People with
hearing loss may become frustrated if they are unable to communicate effectively and may withdraw from interaction with others if hearing loss
is profound. Be sure to utilize communication techniques described in the Chapter 1.3 subsection “Impaired Hearing” to prevent isolation.
Hearing aids make sounds louder but do not help in every environment. Even with hearing aids, it can be difficult for individuals to hear a
conversation in a large open space or if there is other background noise such as music, television, or other conversations.
If a resident has hearing aids, be sure they are cleaned regularly, and change the batteries once a week. Wax can be removed with a monofilament
tool provided with the hearing aids. Some hearing aids have rechargeable batteries that should be charged each night while the resident sleeps.
[9]
See Figure 9.16 for a hearing aid in a case with a battery and a cleaning tool.

Figure 9.16 Hearing Aid in a Case With a Battery and

Cleaning Tool
Hearing aids are expensive for residents to purchase, so it is important to always handle them with care and store them in an appropriate place, so
they are not lost. If you are unsure of how to fit a hearing aid into a resident’s ear, ask for assistance from the nurse. Hearing aids can fit
[10]
completely inside the ear or over the top of the ear. See Figure 9.17 for an example of a hearing aid that is placed over the top of the ear and
[11]
Figure 9.18 for a simulated hearing aid placed inside a mannequin ear.

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 Figure 9.17 Hearing Aid on Top of the Ear

Figure 9.18 Simulated Hearing Aid Placed Inside a Mannequin

Ear

[12]
To experience what someone with hearing loss may hear, watch the following YouTube video : Hearing Loss Simulator – Hear What
Hearing Loss Sounds Like.

Speech Impairment
Speech impairment is common for individuals who have had a stroke or who have experienced injuries to certain parts of their brain. These
injuries can make forming words and understanding conversations difficult. The medical terms for these conditions are expressive aphasia and
receptive aphasia.
People with aphasia can become very frustrated. Everyone has experienced a time when they were trying to think of a word but couldn’t
remember it. Imagine how it would feel if this was your experience every time you were trying to communicate with someone. Just as can
happen with people with hearing loss, clients with aphasia may isolate themselves, avoid interaction, or become agitated and even aggressive if
not approached appropriately.
Interventions when working with a client with a speech impairment include allowing the person extra time to form words or to process what was
spoken to them. The feeling of being rushed can make aphasia worse, so providing ample time to process and respond is key. Writing
conversations on a whiteboard may also be helpful, depending upon the cognition of the person.
A speech therapist plays an integral role in assessing a resident with aphasia and creating a communication plan. A communication book may be
[13]
created so the person can point to images of common phrases or requests instead of trying to remember or say the words. See Figure 9.19 for
an example of a communication board. Refer to the Chapter 1.2, “Overcoming Communication Barriers” subsection for additional information
on overcoming barriers.

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 Figure 9.19 Communication Board

[14]
To learn more about speech impairment, view the following YouTube video : Aphasia: The Disorder That Makes You Lose Your Words –
Susan Wortman-Jutt.

1. “Cataract in human eye.png” by Rakesh Ajuja, MD is licensed under CC BY-SA 3 ↵

2. National Eye Institute. (2020, August 17). Age-related macular degeneration. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-
and-diseases/age-related-macular-degeneration ↵
3. This work is a derivative of Nursing Skills by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. “Snellen-myopia.png” by Daniel P. B. Smith (talk) (Uploads) is licensed under CC BY-SA 3.0 ↵
5. National Eye Institute, NIH. (2018, November 7). See what I see: Cataracts [Video]. YouTube. All rights reserved.
https://youtu.be/nGV3PD5sBgM ↵
6. Pugini, A. (2016, May 21). Glaucoma simulation - Busy road [Video]. YouTube. All rights reserved. https://youtu.be/jkYeC_JDEPs ↵
7. National Eye Institute, NIH. (2018, November 7). See what I see: AMD [Video]. YouTube. All rights reserved. https://youtu.be/Iu5ToTfUOok
↵
8. Introduction to Sensation and Perception by Students of PSY 3031 and edited by Dr. Cheryl Olman is licensed under CC BY 4.0 ↵
9. “Hearing Aid in Case.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
10. “mark-paton-QpOxts03rps-unsplash” by Mark Paton on Unsplash is licensed under CC BY 4.0 ↵
11. “Hearing Aid in Mannequin.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
12. Ear Science Institute Australia. (2017, May 1). Hearing loss simulator - Hear what hearing loss sounds like [Video]. YouTube. All rights
reserved. https://youtu.be/_jpe0_v2nAc ↵
13. “I Need Help” and “Places I Want to Go” by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵
14. TED-Ed. (2016, September 15). Aphasia: The disorder that makes you lose your words - Susan Wortman-Jutt [Video]. YouTube. All rights
reserved. https://youtu.be/-GsVhbmecJA ↵

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9.8: Fall Prevention
“Prevent residents from falling” is one of the National Patient Safety Goals for long-term care centers. Client falls in long-term care
centers, hospitals, or homes are very common and can cause serious injury and death. Older adults have the highest risk of falling.
Each year, three million older people are treated in emergency departments for fall injuries, and over 800,000 are hospitalized
because of a head injury or hip fracture resulting from a fall. Many older adults who fall, even if they’re not injured, become afraid
of falling. This fear may cause them to limit their everyday activities. When a person is less active, they become weaker, which
[1]
further increases their chances of falling.
[2]
Many conditions increase an individual’s risk for falls, including the following :
Lower body weakness
Vitamin D deficiency
Difficulties with walking and balance
Medications, such as tranquilizers, sedatives, antihypertensives, or antidepressants
Vision problems
Foot pain or poor footwear
Environmental hazards, such as throw rugs or clutter that can cause tripping
Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater their chances of falling. Many
[3]
risk factors can be changed or modified to help prevent falls. The best way to prevent falls is to follow these guidelines:
Keep residents as strong and mobile as possible
Utilize the interventions described in the “Assisting With Sensory Deficits” section of this chapter to address any sensory
impairments
Use proper transfer techniques as outlined in Chapter 8.4
Report any weakness, confusion, or change in condition
Encourage fluid and nutritional intake to prevent dizziness and promote strength
Residents are assessed for their potential fall risk by the nursing staff or therapists when they are admitted to a facility, at regular
intervals during their stay, and any time there is a change in their condition or when certain medications are ordered. Nursing
assistants do not perform this assessment but should be aware of factors that can increase fall risk.

View a PDF sample of a fall risk assessment: Johns Hopkins Fall Risk Assessment Tool.

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

This page titled 9.8: Fall Prevention is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra Sandquist Reuter
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9.9: Skills Checklist- Range of Motion (ROM) Exercises for the Shoulder
Note: Includes Shoulder Flexion/Extension and Abduction/Adduction Movements
1. Gather Supplies: None
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Raise the bed height if needed.
Position the resident in supine position (with the bed flat).
Place one of your hands under the resident’s elbow with your palm facing up.
Place your other hand under the resident’s wrist with your palm facing up.
Watch the resident for objective signs of pain during movement.
Move their arm gently and stop if there is any resistance.
While keeping the resident’s arm straight, raise their arm up and over their head (i.e., flexion).
Ask the resident if they are experiencing any pain during movement.
Stop the ROM exercise if the resident reports pain or displays objective signs of pain.
Bring the resident’s arm back down to their side (i.e., extension).
Complete flexion and extension movements of the shoulder according to the order in the restorative care plan.
Continue to support the elbow and wrist of the resident.
Keeping the resident’s arm straight, move their entire arm out away from the body (i.e., abduction).
Move their arm gently and stop if there is any resistance.
Ask the resident if they are experiencing any pain during movement.
Return the resident’s arm to their side (adduction).
Complete abduction and adduction movements of the shoulder according to the order in the restorative care plan.
4. Post-Procedure Steps:
Perform hand hygiene.
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report ROM performed and any skin issues, pain with movement, or other changes noted with the resident.
View a YouTube video of an instructor demonstration of range of motion exercises for the shoulder:

9.9.1 https://med.libretexts.org/@go/page/70412
 Range of Motion Exercises for the Shoul…
Shoul…

1. Chippewa Valley Technical College. (2022, December 3). Range of Motion Exercises for the Shoulder. [Video]. YouTube.
Video licensed under CC BY 4.0. https://youtu.be/9MNw0bO5g0I/ ↵

This page titled 9.9: Skills Checklist- Range of Motion (ROM) Exercises for the Shoulder is shared under a CC BY 4.0 license and was authored,
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9.10: Skills Checklist- Range of Motion (ROM) for the Hip and Knee
Note: Includes abduction/adduction of the hip and flexion/extension of the hip and knee movements.
1. Gather Supplies: None
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Raise the bed height if needed.
Position the resident in the supine position (with the bed flat).
Place one of your hands under the resident’s knee with your palm facing up.
Place your other hand under the resident’s ankle with your palm facing up.
Watch for any objective signs of pain during movement.
Abduction/Adduction for Hip:
Keeping the resident’s leg straight, gently move their entire leg away from their body (i.e., abduction).
Move their leg gently and stop if there is any resistance.
Ask the resident if they are experiencing any pain during movement.
Stop the ROM movement if the resident reports pain or displays objective signs of pain.
Keeping the resident’s leg straight, move their entire leg toward their body (i.e., adduction).
Complete abduction and adduction movements of the hip according to the order in their restorative care plan.
Continue to correctly support joints by keeping one of your hands under the resident’s knee and the other hand under the
resident’s ankle.
Flexion/Extension of Knee and Hip:
Bend the resident’s knee and hip up toward the resident’s trunk (i.e., flexion of hip and knee at the same time).
Move the resident’s leg gently and stop if there is any resistance.
Ask the resident if they are experiencing any pain during movement.
Stop the ROM movement if the resident reports pain or displays objective signs of pain.
Straighten their knee and hip (i.e., extension of knee and hip at the same time).
Complete flexion and extension movements of the knee and hip according to the order in the restorative care plan.
4. Post-Procedure Steps:
Perform hand hygiene.
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report ROM performed and any skin issues, pain with movement, or other changes noted with the resident.
View a YouTube video[1] of an instructor demonstration of range of motion exercises for the hip and knee:

9.10.1 https://med.libretexts.org/@go/page/70414
 Range of Motion Exercises for the Hip a…
a…

1. Chippewa Valley Technical College. (2022, December 3). Range of Motion Exercises for the Hip and Knee. [Video]. YouTube.
Video licensed under CC BY 4.0. https://youtu.be/ynmFa68Rv7w ↵

This page titled 9.10: Skills Checklist- Range of Motion (ROM) for the Hip and Knee is shared under a CC BY 4.0 license and was authored,
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9.11: Skills Checklist- Application of Compression Stockings (TED Hose)
1. Gather Supplies: Compression stockings
2. Routine Pre-Procedure Steps:
Knock on the client’s door.
Perform hand hygiene.
Introduce yourself and identify the resident.
Maintain respectful, courteous, and professional communication at all times.
Provide for privacy.
Explain the procedure to the client.
3. Procedure Steps:
Raise the bed height if needed.
Position the resident in the supine position (bed flat).
Expose only the leg you will be placing the stocking on.
Roll, gather, or turn the stocking inside out to the heel.
Place the stocking over the resident’s toes, foot, and heel.
Check the placement of heel marking.
Roll or gently pull the stocking up their leg.
Check the resident’s toes for possible pressure from stocking.
Adjust stocking as needed; stocking should be wrinkle-free to the knee or hip, depending on length of stocking.
4. Post-Procedure Steps:
Perform hand hygiene.
Check on resident comfort and ask if anything else is needed.
Ensure the bed is low and locked. Check the brakes.
Place the call light or signaling device within reach of the resident.
Open the door and privacy curtain.
Perform hand hygiene.
Document and report application of TED hose and any skin issues, pain with movement, or other changes noted with the
resident.
View a YouTube video[1] of an instructor demonstration of application of compression stockings (TED hose):

Application of Compression Stockings (…

(…

1. Chippewa Valley Technical College. (2022, December 3). Application of Compression Stockings (TED hose). [Video].
YouTube. Video licensed under CC BY 4.0. https://youtu.be/MeV0Kitfy0I ↵

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9.12: Learning Activities

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Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request.

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9.13: IX Glossary
Abduction: The movement of a limb away from the body’s midline. For example, hip abduction is the movement of the leg away
from the midline of the body when getting out of bed.
Active assist range of motion: Movement of a joint by an individual with partial assistance from an outside force.
Active range of motion: Movement of a joint by the individual with no outside force aiding in the movement.
Activity intolerance: The reduction of a person’s stamina and their ability to perform activities.
Adduction: The movement of a limb towards the midline. For example, if a person has their fingers spread wide apart, bringing
them back together is adduction.
Built-up handles: Specialized silverware that allows the use of utensils by individuals with limited functional ability of their
fingers (such as severe arthritis) to hold a smaller handle.
Cataracts: A vision condition causing clouding of the clear lens of the eye.
Coagulate: Form a clot.
Comorbidities: Coexisting health conditions.
Compression stockings: Stockings that apply gentle pressure to a limb to reduce edema; also referred to as thrombo-embolic-
deterrent (TED) hose.
Deep-vein thrombosis (DVT): A blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere
within the cardiovascular system.
Depth perception: The ability to determine distance between oneself and another object.
Dysphagia: A swallowing disorder.
Edema: Fluid retention causing swelling in the extremities.
Expressive aphasia: A speech disorder where a person understands what other people say but struggles to form words.
Extension: Movement that increases the angle between two bones. For example, extension occurs when doing a bicep curl and the
arm is straightened back to starting position, increasing the angle between the elbow joint.
Flexion: Movement that decreases the angle between two bones. For example, contracting the bicep to lift a weight upwards is
flexion.
Glaucoma: A visual condition that occurs due to high pressure on the optic nerve that results in loss of peripheral vision, blind
spots, or even blindness across the entire visual field.
In-patient therapy: Rehabilitation treatment that occurs in a facility where the client is staying.
Macular degeneration: A visual condition that causes a blind spot in the center field of vision and is the leading cause of vision
loss in people over 50.
Occupational therapists: Therapists who assess, plan, implement, and evaluate interventions to help clients achieve their highest
possible level of independence in completing their activities of daily living (ADLs), such as bathing, grooming, eating, and
dressing.
Out-patient therapy: Rehabilitation treatment that occurs when an individual is staying at home and visits a therapist once or
twice a week.
Passive range of motion: When passive range of motion is applied, the joint of an individual receiving the exercise is completely
relaxed while the outside force moves the body part.
Physical therapists: Licensed health care professionals who assess, plan, implement, and evaluate interventions related to clients’
functional abilities in terms of strength, mobility, balance, gait, coordination, and joint range of motion.
Presbycusis: Hearing loss that occurs due to the aging process.
Receptive aphasia: A speech condition that causes difficulty in understanding conversations.

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Rehabilitation: Therapy to help people regain body functions they lost due to medical conditions or injury.
Respiratory therapists: Therapists who treat respiratory-related conditions in patients.
Segmenting ADLs: Breaking up activities of daily living (ADLs) to accommodate a client’s activity intolerance.
Snellen chart: A common tool used for assessing distant vision.
Speech therapists: Therapists who assess, diagnose, and treat communication and swallowing disorders.
Weighted silverware: Specialized silverware with a weighted handle for individuals with tremors or unsteady hands.

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 CHAPTER OVERVIEW

10: Provide Care for Clients Experiencing Acute and Chronic Health Conditions
10.1: Introduction to Provide Care for Clients Experiencing Acute and Chronic Conditions
10.2: History of Care for Individuals With Mental Health Disorders and Developmental Disorders
10.3: Caring for Clients With Developmental Disorders
10.4: Caring for Clients With Mental Health or Substance Use Disorders
10.5: Caring for Clients With Dementia
10.6: Promoting Nutritional Intake
10.7: Caregiver Role Strain
10.8: Learning Activities
10.9: X Glossary

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1
10.1: Introduction to Provide Care for Clients Experiencing Acute and Chronic
Conditions
Learning Objectives
Care for clients with developmental disabilities
Care for clients with long-term, disabling conditions, including dementia
Manage stressful situations involving clients with dementia
Provide food and fluid intake monitoring and interventions for clients with dementia
Manage behavioral challenges of clients with dementia
Demonstrate sensitivity to emotional needs, social diversity, and mental health of clients
Respond to psychosocial needs of clients

Many nursing assistants work in long-term care settings where residents live for assistance with chronic medical conditions.
Chronic health conditions are health issues lasting more than six months and often require specialized interventions to maintain the
individual’s highest possible level of health and functioning. Acute health conditions in long-term care settings are typically related
to the resident’s rehabilitation process, an infection, or an injury.
Nursing assistants also work in hospital settings where patients with acute health conditions can experience rapid changes in their
condition. These changes must be promptly communicated to the nurse so they can be addressed quickly. In this chapter you will
learn how to meet the needs of residents with chronic conditions related to developmental disabilities, mental health disorders, and
dementia. You will also be introduced to providing care for patients with acute conditions that require additional safety or
behavioral interventions.

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10.2: History of Care for Individuals With Mental Health Disorders and
Developmental Disorders
In the past, individuals living with mental health disorders or developmental disorders were viewed as unable to be a part of general
society and were often placed in large institutions with little to no access to the outside environment or the community. This
unfortunate stigma was due to a vast misunderstanding of these diagnoses. We now know this misconception is detrimental to
individuals, and legislative and societal changes have been made to better meet the needs of these individuals. As a health care
professional, it is important to understand how you can continue to improve the quality of life in individuals with these diagnoses
through your communication, awareness, and approach.
[1]
Historically, facilities for institutionalized individuals looked like the Willowbrook State School pictured in Figure 10.1.
Residents were typically cared for in large spaces and group settings and eating at long tables with little space for comfort. Often,
residents slept in large rooms with several beds in close proximity to each other with no accommodations for privacy or noise
reduction. This care environment often caused overstimulation, resulting in sleep disturbances and client behaviors that were
difficult to manage. In contrast to current health care practices, individual preferences were not prioritized.

Figure 10.1 Willowbrook State School

These institutions lacked funding, professional caregivers, and basic knowledge of what residents needed to successfully function
to the best of their ability. Because of these conditions, individuals with developmental or behavioral health disorders were often
looked down upon, shunned, stigmatized, vilified, criminalized, and, in some cases, imprisoned or tortured. This type of inhumane
[2]
treatment has been documented as far back as the Middle Ages in Europe and up until the mid-1900s in the United States.
In the United States, this type of care environment continued until 1963 when President John F. Kennedy signed the Community
[3]
Mental Health Act (as seen in Figure 10.2 ). President Kennedy described this act as “a bold new approach” and provided federal
grants to states to construct community mental health centers (CMHC). This act aimed to improve the diagnosis, treatment, and
delivery of mental health services to individuals and prevent acute episodes that could impact their safety. In 1965 federal funding
[4]
was allocated by the Medicaid Act to statewide institutions to improve conditions, staff education, and treatment of residents.

Figure 10.2 President John F. Kennedy Signing the Community Mental

Health Act

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The Community Mental Health Act resulted in a mass “deinstitutionalization” across the country, and by 1980 the population of
psychiatric hospitals had decreased by nearly 75%. Deinstitutionalization meant that individuals with behavioral and
developmental disorders were cared for in group home settings that allowed for community involvement rather than being isolated
in a facility with little or no interaction with general society. By 2009 less than 2% of individuals with mental health disorders lived
in a large institution, thus greatly increasing their quality of life, attention to their individualized needs and preferences, and their
[5]
ability to be active in the community.
Additional consideration has also been given to school-aged children and adolescents with developmental disorders and disabilities
to be educated in a mainstream environment. In 1975 the Education of Handicapped Children Act was passed to support special
education and related service programming for children and youth with disabilities in public schools. This act mandated that
everyone with an intellectual disability was granted equal access to a free education. It was renamed the Individuals with
Disabilities Education Act (IDEA) in 1990. In 2010 President Barack Obama signed “Rosa’s Law,” which eliminated the term
“mental retardation” and replaced it with “intellectual disability.” Deleting this term from legislation helped to change the negative
stigma associated with disabilities.

Read the following PDF about Rosa’s Law.

The remaining sections of this chapter will describe common developmental disorders, mental health disorders, and dementias you
[6]
may encounter as a caregiver.

1. “Willowbrook_State_School_(NYPL_b15279351-105038)_-_cropped.jpg” by unknown author is in the Public Domain ↵

2. This work is a derivative of Introduction to Social Work at Ferris State University by Department of Social Work and is licensed
under CC BY 4.0 ↵
3. “John_F._Kennedy_Signs_the_Community_Mental_Health_Act_-_ST-C376-2-63.jpg” by Cecil W. Stoughton (1920–2008) is
in the Public Domain ↵
4. This work is a derivative of Introduction to Social Work at Ferris State University by Department of Social Work and is licensed
under CC BY 4.0 ↵
5. This work is a derivative of Introduction to Social Work at Ferris State University by Department of Social Work and is licensed
under CC BY 4.0 ↵
6. What is the Individuals With Disabilities Education Act? by University of Washington is licensed under CC BY-NC-SA 3.0 ↵

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LibreTexts platform; a detailed edit history is available upon request.

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10.3: Caring for Clients With Developmental Disorders
Developmental disorders, also referred to as “intellectual disabilities,” are caused by impairments in the brain or central nervous system. These impairments result
from problems that occurred during fetal development or injuries sustained during birth or early infancy, such as cerebral palsy and autism. Other disorders, such as
[1]
Down syndrome, have a genetic cause.
These impairments can impact mobility, problem-solving, planning, abstract thinking, judgment, academic learning, and learning from experience. Individuals with
[2]
developmental disorders often function at a lower developmental stage than the average person of the same chronological age.

Refer to the Chapter 1.4, “Human Needs and Developmental Stages” section to review “Erikson’s Stages of Development” and what is expected at each stage.

[3]
Intellectual disabilities are diagnosed by health care providers based on two major criteria :
The ability to learn, think, solve problems, and make sense of the world, referred to as intellectual functioning or Intelligence Quotient (IQ).
The skills and abilities to live independently, referred to as adaptive behavior or adaptive functioning.
Intellectual functioning is typically measured by a standardized IQ test. The average score of an IQ test is 100. People scoring below 70 to 75 are thought to have an
intellectual disability.
To measure adaptive behavior, professionals look at what an individual can do in comparison to other individuals their age. Skills important for adaptive behavior
[4]
include the following :
Daily living skills, such as getting dressed, going to the bathroom, and feeding oneself
Communication skills, such as understanding what is said and being able to answer
Social skills with peers, family members, adults, and others
Adaptive behavior is much more about how a person manages in daily life and their ability to do the things that are expected of their age within their culture.
Without ongoing support, deficits in adaptive behavior limit an individual’s functioning in many areas such as communication, social participation, and independent
living at home, school, work, or in the community. A person without adequate adaptive behaviors requires caregivers and other types of resources depending on
their level of impairment. As a nursing assistant, you may be providing most of their needed support.
Levels of severity of intellectual disability and associated care needs can be categorized into mild, moderate, severe, and profound. It is important for nursing
[5]
assistants to know what can be expected and how to care for individuals with these levels of disabilities :
Mild Intellectual Disabilities: In very young children with mild intellectual disabilities, there may be no obvious problems, but as they enter school, they often
demonstrate difficulties in academic skills. As they become adults, abstract thinking and short-term memory are reduced, and communication is more immature
than expected for their age. They may have difficulties regulating their emotions or have impaired social judgment, which puts them at risk of being manipulated
by others. The individual may be independent with their activities of daily living (ADLs) and personal hygiene needs but requires support with shopping,
cooking, housekeeping, and managing money. They may require assistance in finding appropriate leisure activities, as well as making health care decisions and
[6]
legal decisions. Individuals with mild disabilities may be employed in jobs that don’t require much decision-making.
Moderate Intellectual Disabilities: The conceptual skills of individuals with moderate intellectual disability can be observed because they are behind in
development compared to their peers. For school-aged children, their academic achievement is limited, and their learning progress is slow in all areas compared
to their peers. As they become adults, their academic skills typically remain at a primary school level. They rely on spoken words for communication and are
often unable to understand written instructions. They develop personal relationships, although they may not perceive or interpret social cues accurately. Social
judgment and decision-making abilities are limited, and appointed caregivers must assist them with important life decisions. An individual with moderate
intellectual disabilities can achieve most of their ADLs if given appropriate time, verbal cues, and supervision to ensure they complete all personal hygiene
needs. Similar guidance is needed for other household and life skills. Employment requires considerable support from coworkers and supervisors. Disruptive
[7]
behaviors may be present that cause socialization problems.
Severe Intellectual Disabilities: Individuals with severe intellectual disabilities typically have little understanding of written language or concepts involving
numbers, quantities, time, and money. Caregivers must plan extensive support for problem-solving throughout the individual’s life because they are unable to
make decisions regarding their well-being. Spoken language is limited in vocabulary and may be single words or phrases possibly supplemented by gestures,
signs, or pictures. Communication tends to be focused on the here and now within everyday events. Relationships with family members, friends, and familiar
others (like caregivers) are a great source of pleasure and help. Individuals require support for all ADLs and supervision at all times. Some individuals may
[8]
demonstrate disruptive behaviors that are challenging for family members to manage.
Profound Intellectual Disabilities: Individuals with profound intellectual disabilities have very limited conceptual skills and at best can understand concrete
objects but not symbols such as pictures or words. They can learn skills such as matching and sorting based on physical characteristics and may use objects for
specific purposes such as self-care and recreation. They may understand some simple instructions with gestures and often express their desires and emotions
through nonverbal, nonsymbolic communication. They enjoy relationships with well-known family members, caregivers, and familiar others and can initiate
and respond to social interactions through gestural and emotional cues. However, sensory and physical impairments limit the amount and quality of social
interaction, so extensive support may be required to ensure that social interaction occurs. They are dependent on others for all aspects of their care, health, and
safety. If there are no physical impairments, they can assist with simple chores around the home such as putting dishes away. With support, it is possible to
engage them in vocational tasks that depend on simple actions with objects. Recreational activities may involve listening to music, watching movies, going for
walks, or water activities, all with the support of others. Without support, they often spend a lot of time just watching others. They may demonstrate disruptive
[9]
behaviors.
Individuals with developmental disabilities generally have few physical limitations. The majority of their care needs are based on supervised decision-making and
ensuring safety needs are met. Because these impairments begin at a young age, caregivers must provide opportunities for individuals with developmental
disabilities to be as independent as possible and integrated into everyday life. This philosophy is reflected in the legislative acts previously discussed in the “History
of Care for Individuals With Mental Health Disorders and Developmental Disorders” section, with individuals having developmental disorders placed in small,
community-based group homes if their care is unable to be managed by family members in their homes.

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Down Syndrome
Nursing assistants may help support individuals with a common developmental disorder called Down syndrome. People with Down syndrome typically experience
mild to moderate severity levels of intellectual disability with associated adaptive behaviors regarding daily life activities as previously described. Individuals with
Down syndrome also have common physical characteristics based on its genetic cause related to an excess 21st chromosome.
Chromosomes can be thought of as small packages of genes in the body that determine how a baby forms as it develops during pregnancy and functions after birth.
Typically, a baby is born with 46 chromosomes. However, babies with Down syndrome have an extra copy of Chromosome 21. The medical term for having an
extra copy of a chromosome is trisomy, so Down syndrome is also referred to as “Trisomy 21.” This extra 21st chromosome causes common physical features for
[10] [11]
individuals with Down syndrome as seen in Figures 10.3 and 10.4.

Figure 10.3 Infant With Down Syndrome

Figure 10.4 School-Aged Child With Down

Syndrome
[12]
Common physical features of individuals with Down syndrome include the following :
A flattened face, especially the bridge of the nose
Almond-shaped eyes that slant up
A short neck
Small ears
A tongue that tends to stick out of the mouth
Tiny white spots on the iris (colored part) of the eye
Small hands and feet
A single line across the palm of the hand (palmar crease)
Small fifth fingers that sometimes curve toward the thumb
Poor muscle tone or loose joints
Shorter height as children and adults
Most people with Down syndrome have common facial features but no other major birth defects. However, some people with Down syndrome have other major
birth defects and an increased risk of medical problems such as heart or thyroid disease. Common health problems associated with Down syndrome are as
[13]
follows :

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 Hearing loss
Obstructive sleep apnea (breathing temporarily stops while asleep)
Ear infections
Eye diseases
Heart defects present at birth
Individuals with Down syndrome typically enjoy socialization and being part of a group, and finding ways to give them recognition for their achievements is
important. For example, during school years, activities like helping with athletic teams are often enjoyable. After high school, employment provides feelings of self-
esteem and achievement. Because these individuals thrive on encouragement, allowing them the opportunity to be as independent as possible and achieve their
personal goals greatly increases their quality of life. Independence can range from completing ADLs independently, completing school coursework, or gaining
skills from a job.

Autism Spectrum Disorders (ASD)

Nursing assistants may help care for individuals with an autism spectrum disorder (ASD). As the word spectrum infers, there is a wide range of potential behavioral
patterns associated with autism. In contrast with other developmental disorders, individuals with autism can be extremely intelligent. Autism causes individuals to
process environmental stimuli and social interactions in a different way. Sensory stimulation such as lights, sounds, odors, or crowds can cause individuals with
ASD to fidget, call out, or repeat movements that can be perceived by others as outside the social norm. The media often portrays individuals with autism as having
altered social awareness or the inability to show emotion or empathy. Actual behaviors associated with ASD are outlined in the following subsections.

Social Communication
Individuals with autism often have altered social communication with others that becomes apparent early in childhood. Infants with ASD show less attention to
social stimuli, smile and look at others less frequently, and have a decreased response to their name. Toddlers with ASD may demonstrate less eye contact and
taking turns with others and may not have the ability to use simple movements to express themselves. Individuals with severe forms of ASD do not develop enough
[14]
speech ability to meet their daily communication needs with others.

Restricted and Repetitive Behaviors

[15]
Children with ASD may exhibit repetitive or restricted behaviors, including the following :
Stereotypic: Repetitive movements, such as hand flapping, head rolling, or body rocking.
Compulsive behavior: Repetitive acts characterized by the feeling that one “has to” perform them, such as arranging objects in stacks or parallel lines.
Resistance to change: Preference for an unvarying pattern of daily activities, such as insisting that the furniture not be moved.
Restricted behavior: Limited focus, interest, or activities, such as preoccupation with a single television program, toy, or game.
Self-injury: Movements that can cause the person to hurt themselves, such as eye poking, skin picking, hand biting, and head banging.
[16]
Figure 10.5 further explains three functional levels of ASD from the perspective of someone with autism.

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 Figure 10.5 Three Functional Levels of Autism

[17]
View the following YouTube video to learn more about how individuals with autism experience daily life: : What It’s Really Like to Have Autism | Ethan
Lisi.

1. This work is a derivative of Psychology by Jeffrey C. Levy and is licensed under CC BY 4.0 ↵
2. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
3. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
4. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
5. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
6. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
7. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
8. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
9. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
10. “down-syndrome-full-medium.jpg” by National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention is in the
Public Domain. Access for free at
https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html#:~:text=Some%20common%20physical%20features%20of,A%20short%20neck ↵
11. “Boy_with_Down_Syndrome.JPG” by Vanellus Foto is in the Public Domain ↵
12. Centers for Disease Control and Prevention (2021, April 6). Facts about Down syndrome.
https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html#:~:text=Some%20common%20physical%20features%20of,A%20short%20neck ↵
13. Centers for Disease Control and Prevention (2021, April 6). Facts about Down syndrome.
https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html#:~:text=Some%20common%20physical%20features%20of,A%20short%20neck ↵
14. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
15. This work is a derivative of Understanding and Supporting Learners With Disabilities by Paula Lombardi and is licensed under CC BY-NC-SA 4.0 ↵
16. “Three_Levels_of_Autism_1.png” by MissLunaRose12 is licensed under CC BY-SA 4.0 ↵
17. TED. (2020, April 29). What it’s really like to have autism | Ethan Lisi [Video]. YouTube. All rights reserved. https://youtu.be/y4vurv9usYA ↵

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This page titled 10.3: Caring for Clients With Developmental Disorders is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra Sandquist Reuter via
source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request.

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10.4: Caring for Clients With Mental Health or Substance Use Disorders
Nursing assistants provide care for individuals with mental health disorders in many settings. According to the National Alliance
on Mental Illness (NAMI), approximately 1 in 5 adults in the United States experiences some type of mental health disorder. In the
United States, this means that over 43 million people experience a mental health disorder within any given year. Among individuals
who experience a mental health disorder, 9.8 million experience a severe mental health disorder, meaning it dramatically interferes
or limits their ability to function in everyday life. However, of all the adults in the United States with a mental health disorder,
research shows that only 41% received mental health services in the past year, and for those diagnosed with a severe mental health
disorder, only 63% received treatment or services. These numbers demonstrate the need to identify and provide effective treatment
[1]
to individuals living with these disorders.
Just as there are various physical illnesses with varying degrees of severity, there are also various mental health illnesses with
varying degrees of severity. Symptoms of mental health disorders can often be managed with medications, in a similar way that
physical illnesses like diabetes are managed with insulin and other medications. By helping individuals with mental health
disorders manage their medications and attend psychotherapy and/or counseling sessions, caregivers can help individuals with
mental health disorders stabilize their emotions and behaviors and reach their greatest potential in their life.
Being aware of common mental health disorders will allow you, as a caregiver, to understand what the person is experiencing and
how to help them meet their needs in the best possible way. While every case is different, it is important to be aware of how
individuals with mental health disorders may present themselves and start thinking about how you will help manage related
[2]
symptoms and behaviors.
There are several categories of mental health disorders diagnosed by mental health providers such as a psychiatrist, psychologist, or
advanced practice nurse practitioner. This section will further describe these common mental health disorders:
Anxiety Disorders
Psychotic Disorders
Bipolar Disorder
Depressive Disorders
Trauma Disorders
Personality Disorders
Substance Use Disorder

Anxiety Disorders
Anxiety is a universal human experience that includes feelings of apprehension, uneasiness, uncertainty, or dread resulting from a
real or perceived threat. Fear is a reaction to a specific danger, whereas anxiety is a vague sense of dread to specific or unknown
[3]
danger. Everyone experiences feelings of mild anxiety due to situations that occur in their daily lives, such as an upcoming exam,
job interview, sports competition, or other type of performance. However, individuals with anxiety disorders experience more than
temporary worry or fear. The anxiety can worsen over time, and symptoms interfere with their daily functioning. People
experiencing moderate to severe anxiety may also have objective symptoms such as an elevated heart rate, respiratory rate, or
blood pressure.
[4],
There are several types of anxiety disorders, including generalized anxiety disorder, panic disorder, and phobia-related disorders
[5]
:
Generalized Anxiety Disorder (GAD): People with GAD have excessive anxiety and worry about numerous events or
activities (such as work or school performance). The individual finds it difficult to control their anxiety and worry, and it is
associated with symptoms such as restlessness, becoming easily fatigued, difficulty concentrating, irritability, muscle tension,
and sleep disturbances. These symptoms impact daily functioning.
Panic Disorder: People with panic disorder have recurrent panic attacks. Panic attacks are sudden periods of intense fear that
come on quickly and reach their peak within minutes. Attacks can occur unexpectedly or can be brought on by a trigger, such as
a feared object or situation. People experiencing a panic attack may exhibit symptoms such as sweating, trembling, shortness of
breath, chest pain, nausea, increased heart rate, or feelings of losing control.
Phobia: A phobia is an intense fear of specific objects or situations (such as flying, heights, or spiders).
Arachnophobia (fear of spiders) is a common phobia.

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 Agoraphobia is an intense fear of being in open spaces, a crowd, or outside of one’s home alone. People with agoraphobia
often avoid these situations because they fear having a panic attack and, as a result, may become homebound.
Social anxiety disorder is a type of phobia that includes fear or anxiety about social situations where there is possible
scrutiny by others.

Psychotic Disorders
The term psychosis describes conditions when a person experiences a loss of contact with reality and has difficulty understanding
what is real and what is not real. Symptoms of psychosis include hallucinations and delusions. Hallucinations are false sensory
perceptions not associated with real external stimuli and can include any of the five senses (seeing, hearing, feeling, tasting, or
smelling). For example, individuals may experience hallucinations of seeing someone in the room when no one is there, hearing
voices when alone, or smelling something cooking when nothing is being prepared. Some people are aware that their hallucinations
are not real while others cannot separate their hallucinations from reality. Delusions are fixed, false beliefs held by a person even
though there is concrete evidence they are not true. Examples of delusions may include believing that spies can hear your thoughts,
people are poisoning your food, or a celebrity is in love with you. Symptoms of a psychotic episode include delusions,
[6] [7]
hallucinations, incoherent speech, and purposeless excessive movement. ,
Psychosis is a symptom of several mental illnesses, including schizophrenia, bipolar disorder, severe depression, or severe anxiety,
but there are also potential medical causes. Sleep deprivation, medical conditions like hyperglycemia, side effects of certain
prescription medications, and use of alcohol or other drugs can cause psychotic symptoms. Psychosis caused by medical conditions
or substance use is referred to as delirium. It starts suddenly and can cause hallucinations, but it is reversible by treating the cause
of the delirium.
[8],[9]
Nursing assistants can help manage patients’ symptoms of psychosis with the following interventions :
Making sure the room is quiet and well-lit
Having clocks and calendars within view
Inviting family members to spend time in the room
Ensuring hearing aids and glasses are worn
Promoting undisrupted sleep when possible
Getting patients up and out of bed when possible
Schizophrenia is a type of mental illness with symptoms of psychosis that last for at least six months. In addition to symptoms of
psychosis, it also affects how a person feels, with reduced motivation, difficulty concentrating, disinterest or lack of enjoyment in
daily activities, social withdrawal, difficulty showing emotion, and difficulty functioning in daily life activities. It is typically
[10] [11]
diagnosed in the late teen years to early thirties. ,

Depressive Disorders
Depression is a common illness worldwide affecting an estimated 5% of adults. Depression is different from mood fluctuations or
short-lived emotional responses to everyday life stressors or events, such as the loss of a loved one or the end of a relationship.
Depression can become so severe that it affects the individual’s ability to function at work, at school, and in their family roles. It
can cause self-neglect, such as the failure to meet one’s hygiene needs or obtain sufficient nutritional intake. At its worst,
[12] [13]
depression can lead to suicide. ,
During a depressive episode, the person experiences a depressed mood (feeling sad, irritable, or empty) or a loss of pleasure or
interest in activities they normally enjoy. Other symptoms may include poor concentration, feelings of excessive guilt or low self-
worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight, and feeling
fatigued.

Bipolar Disorders
Bipolar disorders include shifts in mood from abnormal highs (called manic episodes) to abnormal lows (i.e., depressive
episodes). These shifts cause significant impairment in the person’s functioning socially or at work. A manic episode is an elevated
or irritable mood with abnormally increased energy that lasts at least one week. As the manic episode worsens, the individual may
become psychotic with hallucinations. During a manic episode, the person often experiences a reduced need to sleep or eat and can
exhibit risky behaviors like excessive buying sprees, unrestrained gambling, or sexual indiscretions. Depressive episodes have
[14] [15]
opposite symptoms of manic episodes and are exhibited by low energy, low motivation, and loss of interest in daily activities. ,

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Trauma Disorders
Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or
emotionally harmful or life-threatening and can have lasting adverse effects on their functioning and mental, physical, social,
emotional, or spiritual well-being. For example, a person may experience trauma from an event like a mass shooting, physical
assault, rape, violent accident, or after natural disasters such as hurricanes or tornadoes. Trauma is also associated with experiences
by military personnel/veterans or victims of war.
[16] [17]
,
Types of trauma disorders include the following :
Post-traumatic stress disorder (PTSD) is a disorder that can be caused by experiencing, witnessing, or hearing about a traumatic
event. After a month of being removed from the event, a person may continue to experience sleeplessness, increased heart rate,
mood shifts, physically lashing out, or any combination of responses. These responses may be brought on by any environmental
stimuli that reminds the person of the terrifying event or by recurring thoughts about the event.
Acute stress disorder is a disorder that has similar symptoms as post-traumatic stress disorder, but the symptoms only last for
three days to one month. If symptoms last for longer than one month, it meets the criteria for PTSD. This disorder is
experienced by individuals who have been exposed to actual or threatened death, serious injury, or sexual violence. It can be
caused by directly experiencing the event, witnessing the event, learning the event occurred to a close family member or friend,
[18]
or experiencing repeated exposure to details of traumatic events.

Personality Disorders
A person’s personality is a relatively stable pattern of thinking, feeling, and behaving that evolves over their lifetime. A
personality disorder is a pattern of inner experiences and behaviors that deviates from the expectations of the individual’s culture.
It can be traced back to adolescence or early adulthood and leads to impaired functioning the remainder of the person’s life.
There are ten types of personality disorders that can include distrust of others, isolation, habitual lying, and aggressive or violent
[19] [20] [21]
acts with little remorse. Three common personality disorders are as follows , , :
Obsessive-compulsive personality disorder (OCD): OCD includes a pattern of preoccupation with orderliness, perfectionism,
and control. This preoccupation may impair one’s social life, health, or ability to function in the outside environment. This is
the most common personality disorder in the United States.
Borderline personality disorder: Borderline personality disorder includes a pattern of instability in interpersonal relationships,
altered self-image and emotions, and significant impulsivity. People with borderline personality disorder may experience
chronic feelings of emptiness and exhibit frantic efforts to avoid real or imagined abandonment. They may have difficulty
controlling their anger or experience dissociative symptoms where they feel detached from their body with a loss of memory of
the experience.
Narcissistic personality disorder: Narcissistic personality disorder includes a pattern of grandiosity, need for admiration, and
lack of empathy for others.

Substance Use Disorders

Prolonged, repeated misuse of substances can produce changes to the brain that can lead to substance use disorder. Substances
may include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, or misuse of other prescription or
over-the-counter medications. All these substances taken in excess have a common effect of intensely activating the reward system
in the brain so much that normal life activities may be neglected. Substance use disorder (SUD) is an illness caused by repeated
[22]
misuse of these substances.
Over 40 million Americans are diagnosed with SUD (14.5% of the population). Severe substance use disorders are commonly
referred to as addiction. Addiction is associated with compulsive or uncontrolled use of one or more substances. Addiction is a
chronic illness that has the potential for relapse or recovery. Relapse refers to the return to substance use after a significant period
of abstinence. Recovery is a process of change when individuals improve their health and wellness and strive to reach their full
potential. Individuals with severe SUD can overcome their disorder with effective treatment and regain health and social
[23]
functioning, referred to as remission.

Care Considerations
Treatment for mental health and SUDs often involves a variety of approaches such as medication, individual or group therapy, and
peer support groups. These interventions may happen in an outpatient or inpatient setting. While you will not be involved in

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providing these treatments as a nursing assistant, it is important to understand what someone with any of these diagnoses is
experiencing. Your support and the manner in which you provide assistance can make a large impact on the quality of life for those
in recovery.
When providing ADLs and other assistance for those with mental health disorders, substance use disorders, or developmental
disorders, the same considerations apply as when providing care to any individual with respect to promoting their dignity, privacy,
and preferences. It is also important to be aware of exposure to potential situations or environments that may feel overwhelming to
the individual and/or trigger their symptoms or behaviors.
Major themes of care to implement for individuals with developmental, mental health, or substance use disorders include the
following:
Communication: As with all caregiving relationships, work to build a trusting relationship through good communication.
Allow time for the client to talk about any concerns and report any changes in outlook to the nurse for additional support. When
providing care, explain the procedure and look for body language, as well as verbal cues, to determine the client’s level of
comfort.
Routine: Keep things as predictable as possible. The daily schedule should remain as consistent as possible by waking,
providing meals, engaging in activities, and going to bed around the same times each day. Staff involved in personal care and
other support should remain consistent whenever feasible. Change and unexpected situations can provoke anxiety in anyone but
can be especially upsetting for people with mental health, substance use, or developmental disorders.
Empathy: Remember that interactions with the environment, family, friends, and caregivers are often processed differently by
those with mental health or development disorders and may result in disruptive behaviors. Do not take their behaviors
personally or assume they are trying to be difficult, but instead be aware their ability to respond calmly or cope with excessive
stimuli or interactions may be diminished.
Redirect or Reapproach: If a client with a developmental or mental health disorder displays disruptive behaviors, focus on
their safety and determine what is absolutely necessary to accomplish at this point in time. Do not focus on completing a task
now if doing it at a later time when the client is calmer will have the same outcome. Attempt to redirect their attention by
carefully encouraging engagement in another activity that may be more appealing or by tactfully changing the subject of a
conversation that may be upsetting. For example, if a resident becomes agitated because they don’t want to get dressed right
away in the morning, will it matter if they wear their pajamas until they need to go outside of their room? You can reapproach
them at a later time when they may be calmer. This is no different than accommodating preferences for any resident.
There are specific care considerations based on the individual’s diagnosis and things the caregiver should be aware of when trying
to meet their personal needs. See Table 10.4 for care considerations for individuals with mental health and developmental
disorders.
Table 10.4 Care Considerations for Individuals With Mental Health and Developmental Disorders

Diagnosis Strategies to Approach Care

Allow time to talk about the situation causing feelings of fear or anxiety
(if they are willing to talk about it). If change causes anxiety, determine
Anxiety Disorder
if being aware of change in advance will cause less anxiety based on the
individual’s preferences.
Listen to the patient’s expression of their feelings when providing care.
Encourage them to be independent and participate in activities, even if
this means 1:1 socialization. Recognize and reinforce their efforts at
Depressive Disorder
participating in their cares or socializing with others. Encourage
effective coping strategies like physical activity, meditation, journaling,
art, and music.
During manic episodes, encourage rest and nutrition. Allow time to
Bipolar Disorder discuss overwhelming feelings or situations. Use approaches for
depressive disorders during low periods.

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 Empathize and provide safety if they are experiencing hallucinations.
Do not contradict what they may be visualizing. Validate their
Schizophrenia experiences with statements such as, “That must be scary for you; how
can I help?” Check for lighting or sounds that may be triggering
hallucinations and move to a different room or area as needed.
Maintain a consistent environment and routine. Be aware of things that
Post-Traumatic Stress Disorder (PTSD)
may overstimulate them or trigger stressful feelings.
Support healthy decisions, encourage recovery, and promote self-
Substance Use Disorder
esteem.
Provide ample time when explaining tasks and give choices to
Down Syndrome
encourage independence. Establish routines and rewards.
Be aware of situations or experiences that may cause overstimulation
Autism and make them feel overwhelmed. Provide time for alone time or
independent activities.

1. This work is a derivative of Introduction to Social Work at Ferris State University by Department of Social Work and is licensed
under CC BY 4.0 ↵
2. This work is a derivative of Introduction to Social Work at Ferris State University by Department of Social Work and is licensed
under CC BY 4.0 ↵
3. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
5. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
6. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
7. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
8. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
9. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
10. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
11. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
12. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
13. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
14. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
15. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
16. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
17. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
18. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
19. This work is a derivative of Introduction to Social Work at Ferris State University by Department of Social Work and is licensed
under CC BY 4.0 ↵
20. This work is a derivative of Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College and is
licensed under CC BY 4.0 ↵
21. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
22. American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵
23. Substance Abuse and Mental Health Services Administration, & Office of the Surgeon General. (2016). Facing addiction in
America: The surgeon general's report on alcohol, drugs, and health. United States Department of Health and Human Services.
https://www.ncbi.nlm.nih.gov/books/NBK424857/ ↵

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This page titled 10.4: Caring for Clients With Mental Health or Substance Use Disorders is shared under a CC BY 4.0 license and was authored,
remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a
detailed edit history is available upon request.

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10.5: Caring for Clients With Dementia
Dementia is a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with
daily life. Disorders grouped under the general term “dementia” are caused by abnormal brain changes. These changes in brain cells affect their
communication with each other, affecting a person’s thinking (i.e., cognitive abilities), behaviors, and feelings. There are many types of dementia.
Alzheimer’s disease is the most common type of dementia. Vascular dementia is the second most common cause of dementia, followed by frontal-
[1]
temporal dementia and Lewy body disease. While there are various causes of dementia, the observable characteristics are similar.
Signs and symptoms of dementia include forgetfulness, impaired decision-making, and decreased thinking abilities that interfere with daily living.
It is gradual and progressive, meaning the signs of dementia start out slowly and gradually get worse over time. Some examples of decreased
[2]
thinking include changes in the ability to perform the following actions :
Recalling things from short-term memory
Keeping track of a purse or wallet
Paying bills
Planning and preparing meals
Remembering appointments
Traveling out of the neighborhood
Dementia typically starts later in life, but it can begin as early as the mid-40s. It is not an expected part of aging. There is no cure for dementia, and
the effects are irreversible. However, appropriate care improves the safety and the quality of life for individuals affected by dementia and their
[3]
loved ones.

Types of Dementia
Various types of dementia are further described in the following subsections.

Alzheimer’s Disease
About 10% of people older than 65 are affected by Alzheimer’s disease (AD). AD is the most common type of dementia and accounts for 60-80%
of cases. Changes in the brain may begin a decade or more before impaired short-term memory and other cognitive problems appear, and the
brain’s functioning continues to decline over time.
Scientists continue to unravel the complex brain changes involved in the onset and progression of AD. Abnormal deposits of proteins occur
throughout the brain and form structures called amyloid plaques and tau tangles, causing previously healthy nerve cells (neurons) to stop
functioning, lose connections with other neurons, and die. The damage initially appears to take place in the hippocampus and the cortex, the parts
of the brain that are essential for forming memories. As additional neurons die, more parts of the brain are affected and begin to shrink. By the final
[4] [5]
stage of AD, damage is widespread, and brain tissue has shrunk significantly. See Figure 10.6 for images comparing a healthy brain to the
changes that occur during AD.

Figure 10.6 Changes in Neurons and the Brain Caused by Alzheimer’s Disease
There is no single diagnostic test that can determine if a person has AD. Health care providers use a patient’s medical history, mental status tests,
physical and neurological exams, and diagnostic tests to diagnose AD and other types of dementia. During the neurological exam, reflexes,
coordination, muscle tone and strength, eye movement, speech, and sensation are tested. While there is no cure for AD, there are medications to
[6]
reduce progression of the symptoms of memory loss and confusion, as well as interventions to manage common symptomatic behaviors.

Vascular Dementia
Vascular dementia occurs at a younger age than Alzheimer’s disease with most symptoms starting around age 60. Vascular dementia is the second
most common type of dementia worldwide and affects about 10-20% of patients with dementia. It is caused by microscopic bleeding and blood
vessel blockage in the brain and is also called multi-infarct dementia. High blood pressure and strokes are common causes of vascular dementia.

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The onset of vascular dementia is typically abrupt and followed by a rapid decline in functioning, in comparison to the slow progression of
Alzheimer’s disease. Common symptoms in vascular dementia include apraxia and agnosia. Apraxia is the impaired ability to carry out motor
activities despite intact motor function. This means the person can understand instructions and has the ability to complete an action but cannot
[7]
process the cue to actually perform the task. Agnosia is the failure to recognize or identify objects despite intact sensory function.

Lewy Body Dementia

Lewy body dementia (LBD) affects approximately 10 to 20% of patients with dementia. Like Alzheimer’s disease, LBD causes a progressive
decline in cognition, leading to a functional impairment in daily activities. This type of dementia typically appears around age 70, and Parkinson’s
disease and sleep disorders are often precursors to being diagnosed with LBD.
Significant features of LBD are fluctuating cognition, visual hallucinations, and sleep disturbances that affect motor and psychiatric functioning.
These factors increase the risk of falls, infection, and malnutrition. Individuals with LBD frequently have aggressive behaviors. Medications used
[8]
for treating dementia are less effective for LBD and often result in more adverse side effects than with other types of dementia.

Frontotemporal Dementia
Frontotemporal dementia (FTD) is caused by degeneration of neurons in the frontal and anterior temporal lobes of the brain. In patients older than
65 years, it is the third most common cause of dementia. For individuals younger than 65 years, it is the second most common cause of early-onset
dementia and commonly affects patients ranging from 45 to 65 years of age.
Genetics plays a key role in the development of FTD with approximately 40% of cases familial in origin. Head trauma and thyroid disease have
also been linked to the development of FTD. Individuals who have experienced head trauma are three times more likely to develop FTD, and
individuals with thyroid disease are over twice as likely to develop this type of dementia.
FTD targets brain areas that are responsible for personality, behavior, language learning, motivation, abstract thinking, and executive function.
Behavior changes and/or language difficulties are common symptoms, followed by loss of cognitive abilities and executive functioning like
[9]
planning, organizing, and self-control.

Stages of Dementia
Stages of dementia are often classified as early, moderate, or advanced.

Early Dementia
[10]
There are ten symptoms of early dementia :
Memory loss that disrupts daily life. This type of memory loss refers to forgetting recently learned information that disrupts daily life, such as
forgetting important dates or events, asking the same questions over and over, and increasingly needing to rely on memory aids (e.g., reminder
notes or electronic devices). They often rely on family members for things they used to handle on their own. These impairments are different
from typical age-related changes, like sometimes forgetting names or appointments but remembering them later.
Challenges in planning or solving problems. This includes changes in an individual’s ability to develop and follow a plan or work with
numbers. For example, they may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty
concentrating and take much longer to do things than they did before. This is more severe and frequent than typical age-related changes of
making occasional errors when managing finances or household bills.
Difficulty completing familiar tasks. This includes trouble driving to a familiar location, organizing a grocery list, or remembering the rules of
a favorite game. This symptom is different from a typical age-related change of occasionally needing help to use microwave settings or to
record a TV show.
Confusion with time or place. This includes losing track of dates, seasons, and the passage of time. Individuals may have trouble
understanding something if it is not happening immediately. Sometimes they may forget where they are or how they got there. This symptom is
different from a typical age-related change of forgetting the date or day of the week but figuring it out later.
Trouble understanding visual images and spatial relationships. Vision problems that include difficulty judging distance, determining color
or contrast, or causing issues with balance or driving can be symptoms of Alzheimer’s disease. This is different from typical age-related visual
changes. (See the Chapter 9.7, “Visual Impairment” subsection for more information on common vision problems.)
New problems with words in speaking or writing. Individuals with Alzheimer’s disease may have trouble following or joining a
conversation. They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves. They may
struggle with vocabulary, have trouble naming a familiar object, or use the wrong name (e.g., calling a “watch” a “hand-clock”). This is
different from a typical age-related change of having trouble finding the right word.
Misplacing things and losing the ability to retrace steps. A person with Alzheimer’s disease may put things in unusual places. They may lose
things and be unable to go back over their steps to find them again. They may accuse others of stealing, especially as the disease progresses.
This is different from a typical age-related change of misplacing things from time to time and retracing steps to find them.
Decreased or poor judgment. Individuals with Alzheimer’s disease may experience changes in judgment or decision-making. For example,
they may use poor judgment when dealing with money or pay less attention to grooming or keeping themselves clean. This is different from a
typical age-related change of making a bad decision or mistake once in a while, like neglecting to change the oil in the car.

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 Withdrawal from work or social activities. A person living with Alzheimer’s disease may experience changes in the ability to hold or follow
a conversation. As a result, they may withdraw from hobbies, social activities, or other engagements. They may have trouble keeping up with a
favorite team or activity. This is different from a typical age-related change of sometimes feeling uninterested in family or social obligations.
Changes in mood and personality. Individuals living with Alzheimer’s disease may experience mood and personality changes. They can
become confused, suspicious, depressed, fearful, or anxious. They may be easily upset at home, with friends, or when out of their comfort zone.
This is different from a typical age-related change of developing very specific ways of doing things and becoming irritable when a routine is
disrupted.

Moderate Dementia
[11]
In moderate stages of dementia, people may experience the following symptoms :
Needing additional assistance with reminders to eat, wash, and use the restroom.
Needing help in recognizing family and friends. Sometimes showing a photo of the person at a younger age will trigger their remaining long-
term memory of that person.
Wandering, getting lost, hallucinations, delusions, and repetitive behavior.
Perseverating on a task, meaning they repeat something over and over. The person feels compelled to do something, such as call a family
member, get groceries, or pick up their children. It often is linked to a responsibility they had as a younger person before memory impairment
occurred.
Hoarding of everyday objects. In a facility, this could be things like sugar or ketchup packets, straws, or salt and pepper shakers.
Rummaging through items in drawers. This can be upsetting to others in a facility as the person may likely go into other residents’ rooms, not
realizing it is inappropriate.
Engaging in risky behavior, such as leaving the house in clothing inappropriate for weather conditions or leaving the stove burners on. If living
in a facility, individuals may try to leave when it is not safe to do so (referred to as eloping).
Demonstrating restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade. This is referred to as
sundowning. (Sundowning will be covered in more detail in the “Managing Sundowning” discussion later this section.)
In the moderate stage of dementia, people who pace or wander may not feel comfortable sitting down for a meal. Finger foods, frequent healthy
snacks, and nutritionally enriched beverages can be offered to help maintain their nutritional intake.

Advanced Dementia
[12]
Those with advanced dementia may experience the following symptoms :
Urinary and/or bowel incontinence.
Increasing need for assistance in washing, dressing, eating, and toileting.
Unsteady gait or shuffling while walking, progressing to the inability to walk.
Increased aggressive behavior, disinhibition (inappropriately acting on sexual desires), or inappropriate laughing.
Difficulty eating, swallowing, and speaking.
Increased time for processing conversations and following directions, progressing to unresponsiveness.
Modified diet such as thickened fluids and a soft or pureed diet.
Seizures may develop in advanced stages.
[13]
To learn more about how Alzheimer’s changes the brain, view the following YouTube video : How Alzheimer’s Changes the Brain.

Caring for Individuals With Dementia

As dementia progresses and cognition continues to deteriorate, care must be individualized to meet the needs of the patient and family. Providing
patient safety and maintaining quality of life while meeting physical and psychosocial needs are important aspects of nursing care. Unsafe
[14]
behaviors put individuals with dementia at increased risk for injury.
Similar to those with intellectual disabilities, individuals with dementia can be very physically mobile. Their decreased awareness of safety paired
with good physical mobility means they require constant oversight as the disease progresses. Disruptive behaviors often occur due to the patient
having a need or emotion without the ability to express it due to the changes in their brain. These needs may be untreated pain, hunger, anxiety, or
the need to use the bathroom. Without the ability to communicate these needs, the individual may display agitation, aggression, shouting,
combativeness, and many other behaviors that can be distressing for all involved. The patient’s family members and caregivers require education
and support to recognize that behaviors are a symptom of dementia and/or a communication of their needs rather than being upset with the
caregiver. As a nursing assistant, the more familiar you are with a client, the easier it becomes to understand their behaviors and provide activities
[15]
to keep their emotions stable while proactively meeting their care needs.

Providing Validation Therapy

Caring for individuals with dementia can be difficult, especially for family members who have trouble understanding what is happening to their
loved one. They may try to reorient the person to the present time and situation, which can be frustrating for a person with dementia because they
are unable to process these cues.

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One of the most effective methods used to assist people with dementia is called validation therapy, meaning you support the reality the person
with dementia is experiencing and do not attempt to reorient them. Begin by determining what the person is perseverating on and figure out a way
to satisfy their need or respond to their emotion. For example, if a person with dementia is perseverating on the need to catch an imagined bus, you
can sit with them by a window and tell them you will have a conversation until the bus arrives. If they are looking for a child they recall from their
past experiences, allow them to hold a doll or call the “child” they are looking for on the phone. After they feel their concerns are validated, it will
be easier to redirect them to another activity and reduce their emotional response.
Remember that individuals with dementia still retain long-term memories, and these memories often provide comfort and ease anxiety. It is helpful
to provide activities similar to those they formerly enjoyed or simulate situations that resemble their prior work or home environment. For example,
if a person was a homemaker, allow them to fold laundry or towels. If they enjoyed working with their hands, provide nuts and bolts to put together
and take apart. If they worked in an office, folding letters and placing them in envelopes may be helpful. Activities like sorting cards, doing simple
crafts, or baking may also be enjoyable. In the early to moderate stages of dementia, ambulation, chair exercises, or range of motion exercises can
help to utilize pent-up energy that can otherwise lead to agitation.
Keeping the environment similar to their previous home can also be a calming factor by helping them recognize where their room is and reducing
wandering or the risk of entering a room that does not belong to them. Some care facilities paint the doorframe like the resident’s home, use plates
and utensils from the resident’s kitchen, and bring furniture from their home as well.
The “Dementia Village” is an entire neighborhood in Holland, complete with movie theater, restaurants, and stores and all staffed with specialized
dementia caregivers. The neighborhood is enclosed, allowing residents to walk on their own without the risk of wandering and getting lost or
[16]
risking safety. View the following YouTube video about how this community is set up : CNN’s World’s Untold Stories: Dementia Village.

Managing Sundowning
Sundowning refers to restlessness, agitation, irritability, or confusion that typically begins or worsens as daylight begins to fade and can continue
into the night, making it difficult for patients with dementia to sleep. Being overtired can increase late-afternoon and early-evening restlessness.
[17]
Tips to manage sundowning are as follows :
Take the resident outside or expose them to bright light in the morning to reset their circadian rhythm.
Do not plan too many activities during the day. A full schedule can be overtiring.
Make early evening a quiet time of day. Play soothing music or ask a family member or friend to call during this time.
Close the curtains or blinds at dusk to minimize shadows and the confusion they may cause.
Reduce noise, clutter, or the number of people in the room.
Do not serve coffee, cola, or other drinks with caffeine late in the day.

Managing Aggressive Behaviors

Aggressive behaviors may be verbal or physical. They can occur suddenly, with no apparent reason, or result from a frustrating situation. While
aggression can be hard to cope with, understanding this is a symptom of dementia and the person with dementia is not acting this way on purpose
[18] [19]
can help caregivers respond. See Figure 10.7 for an image of a resident with dementia demonstrating aggressive verbal behavior.

Figure 10.7 A Resident Displaying Aggressive Verbal

Behavior
There are many therapeutic methods for a nurse or caregiver to initially respond to aggressive behaviors displayed by a person with dementia as
previously described in the “Caring for Clients With Mental Health or Substance Use Disorders” section:
Communication
Routine
Empathy
Redirect or reapproach
Aggression can be caused by many factors including physical discomfort, environmental factors, and poor communication. If a person with
[20]
dementia becomes aggressive, consider what might be contributing to the change in behavior and address it.
Physical Discomfort
Is the person able to let you know that they are experiencing physical pain? It is not uncommon for people with dementia to have urinary tract
or other infections. Due to their loss of cognitive function, they are unable to articulate or identify the cause of physical discomfort and,
therefore, may express it through physical aggression.

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 Is the person tired because of inadequate rest or sleep?
Is the person hungry or thirsty?
Are medications causing side effects? Side effects are especially likely to occur when individuals are taking multiple medications for several
[21]
health conditions.
Environmental Factors
Is the person overstimulated by loud noises, an overactive environment, or physical clutter? Large crowds or being surrounded by unfamiliar
people – even within one’s own home – can be overstimulating for a person with dementia.
Does the person feel lost?
What time of day is the person most alert? Most people function better during a certain time of day; typically, mornings are best. Consider the
time of day when making appointments or scheduling activities. Choose a time when you know the person is most alert and best able to process
[22]
new information or surroundings.
Poor Communication
Are your instructions simple and easy to understand?
Use simple language.
Limit choices to one or two options. (Example: “Do you want to wear the blue shirt or the black shirt?”)
Be sure communication techniques take sensory deficits into consideration.
Try physically demonstrating instead of verbally instructing; use pictures or gestures.
Are you asking too many questions or making too many statements at once? Give ample time to process and respond.
[23]
Is the person picking up on your own stress or irritability? Take a moment for deep breathing or ask another caregiver to assist if available.
Other Techniques
[24]
The following techniques are additional strategies that can be used with aggressive behavior :
Begin by trying to identify the immediate cause of the behavior. Think about what happened right before the reaction that may have triggered
the behavior. Rule out pain as the cause of the behavior. Pain can trigger aggressive behavior for a person with dementia.
Focus on the person’s feelings, not the facts. Look for the feelings behind the specific words or actions.
Try not to get upset. Be positive and reassuring and speak slowly in a soft tone and seek help from another caregiver if needed.
Limit distractions. Examine the person’s surroundings and adapt them to avoid future triggers.
Implement a relaxing activity. Try music, massage, or exercise to help soothe the person.
Shift the focus to another activity (redirect). The immediate situation or activity may have unintentionally caused the aggressive response, so try
a different approach.
Take a break if needed. If the person is in a safe environment and you are able, walk away and take a moment for emotions to cool.
Ensure safety! Make sure you and the patient are safe. Be aware of movement of the patient’s hands and feet and protect yourself from being hit
or kicked. Avoid potential strangulation hazards like retractable lanyards. If interventions do not successfully calm down an aggressive patient,
seek assistance from other staff members. If it is an emergency situation, call 911 and be sure to tell the responders the person has dementia that
is causing them to act aggressively.

Responding to a Person Having Hallucinations

When responding to a person experiencing hallucinations, be cautious. First, assess the situation and determine whether the hallucination is a
problem for the person or for you. Is the hallucination upsetting? Is it leading the person to do something dangerous? Is the sight of an unfamiliar
face causing the person to become frightened? If so, react calmly and quickly with reassuring words and a comforting touch. Do not argue with the
person about what they see or hear. If the behavior is not dangerous, there may not be a need to intervene. Utilize aspects of validation therapy by
[25]
doing the following :
Offer reassurance. Respond in a calm, supportive manner. You may want to respond with, “Don’t worry. I’m here. I’ll protect you. I’ll take care
of you.” Gentle patting may turn the person’s attention toward you and reduce the hallucination.
Acknowledge the feelings behind the hallucination and try to find out what the hallucination means to the individual. You might want to say, “It
sounds as if you’re worried,” or “This must be frightening for you.”
Use distractions. Suggest a walk or move to another room. Frightening hallucinations often subside in well-lit areas where other people are
present. Try to turn the person’s attention to music, conversation, or activities they enjoy.
Respond honestly. If the person asks you about a hallucination or delusion, be honest. For example, if they ask, “Do you see the spider on the
wall?,” you can respond, “I know you see something, but I don’t see it.” This way you’re not denying what the person sees or hears and
avoiding escalating their agitation.
Modify the environment. Check for sounds that might be misinterpreted, such as noise from a television or an air conditioner. Look for lighting
that casts shadows, reflections, or distortions on the surfaces of floors, walls, and furniture. Turn on lights to reduce shadows. Cover mirrors
with a cloth or remove them if the person thinks they are looking at a stranger.

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Managing Wandering
Wandering is the simple act of a person walking around with no purpose due to confusion regarding their location or environment. It can occur in
any stage of dementia. Wandering can be unsafe if the person should not be ambulating independently or if they are attempting to leave home or a
facility resulting in them becoming lost without supervision. It is especially risky during cold winter months when there is the potential for
hypothermia because the person won’t realize their need for warm clothing or to return indoors.
Offering opportunities for exercise or other physical movement (like range of motion exercises) several times throughout the day can reduce the
urgency for people to move about unsafely. If the person does not want to participate in physical movement, any engaging experiences such as
sorting items, arts and crafts, baking, or folding clothes can help to keep residents safe.
A possible intervention for wandering is a device called a wanderguard. This device is a bracelet that has a tracking device. The wanderguard can
be worn on the wrist or ankle. Some facilities place the wanderguard on a resident’s walker or wheelchair; however, by choosing either of these
locations, the wanderguard is only effective when the resident is using that particular device. The wanderguard allows the location of the person
wearing it to be monitored via an app on a phone or other device such as a tablet or laptop. Multiple wanderguards can be activated and monitored
at the same time on one device. The wanderguard sounds an alarm when the wearer comes into close proximity with any exits such as elevators,
[26]
doors, and windows. It may also initiate locking of doors and disabling of elevator buttons to assist in keeping residents safe. See Figure 10.8 for
an image of a wanderguard placed on a resident’s wrist.

Figure 10.8 Wanderguard Bracelet. This image is included on the

basis of Fair Use.

1. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?

utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
2. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. “Alzheimers_Disease.jpg” by BruceBlaus is licensed under CC BY-SA 4.0 and “24239522109_6b061a9d69_o.jpg” by NIH Image Gallery is
licensed under CC0 ↵
6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
7. Abnormal Psychology by Lumen Learning is licensed under CC BY 4.0 ↵
8. This work is a derivative of A Long Goodbye: Ed and Mary’s Journey With Lewy Body Dementia by James Cook University and is licensed
under CC BY-NC-ND 4.0 ↵
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utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
11. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
12. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
13. National Institute on Aging. (2017, August 23). How Alzheimer's changes the brain [Video]. YouTube. All rights reserved.
https://youtu.be/0GXv3mHs9AU ↵
14. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
15. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
16. CNN. (2013, July 10). CNN’s world’s untold stories: Dementia village [Video]. YouTube. All rights reserved. https://youtu.be/jwt4uGYGGUA
↵
17. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
18. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

10.5.6 https://med.libretexts.org/@go/page/70423
19. “5012292106_507e008c7a_o.jpg” by borosjuli is licensed under CC BY 2.0 ↵
20. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
21. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
22. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
23. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
24. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
25. Alzheimer's Association. (n.d.). What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia?
utm_source=google&utm_medium=paidsearch&utm_campaign=google_grants&utm_content=dementia&gclid=Cj0KCQjwvqeUBhCBARIsA
Odt45Z-WN2Wk5Tw07mB7PRGJ3axLWBDxeaooRqavb7_E7n3wQacrGvghdwaAqoXEALw_wcB ↵
26. "wanderguard-blue-tag-2.jpg" by unknown author is included on the basis of Fair Use. Access original image at
https://www.stanleyhealthcare.com/products/wanderguard-blue-bracelet. ↵

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10.6: Promoting Nutritional Intake
When a client is unable to accurately process information, this can lead to problems with food and fluid intake. They may not
understand the process any longer, or they may not be able to follow the commands of opening their mouth, chewing, or
swallowing. General considerations for promoting food and fluid intake are discussed in the Chapter 5.7, “Assisting With Nutrition
and Fluid Needs” section, and the Chapter 6.2, “Nutrition and Fluid Needs” section also discusses assisting individuals with
dementia, developmental disorders, or mental health disorders. The therapeutic techniques of using good communication,
displaying empathy, keeping a routine, and reapproaching can also be utilized.
Aspiration risk also increases as dementia worsens, so individuals with advanced dementia may require thickened liquids and
mechanical soft or pureed texture diet orders to prevent aspiration risk. Tube feeding may be initiated according to the client’s
preferences or at the discretion of their appointed power of attorney for health care.
There are several actions a nursing assistant can take to promote food intake. If the patient has difficulty with the motor skills of
eating or drinking, determine if sensory deficits may be the issue. If the dining area is noisy, try moving them to a quieter area
where it may be easier to hear prompts. Bringing the person near the area where food is prepared can increase their appetite by
smelling the aromas of the meal. After the food is served, position the food in the client’s direct line of vision. Put a small amount
of food on a spoon and hold it gently to the lips, allowing ample time for them to process the feeling and open their mouth.
Multitextured foods like cereal in milk can contribute to confusion over whether to chew or swallow. It may take a long time for the
person to swallow, or they may have difficulty swallowing. Remind the person to tuck their chin towards their chest to reduce
aspiration risk and aid in swallowing. If the person is holding the food in their mouth, gently rub their neck over their throat
because this often prompts them to swallow. People with dementia and some with developmental disabilities may “pocket” their
food, meaning they keep it in their cheeks and don’t swallow it. You may have to use an oral swab after meals to be certain that
there is no food left in their mouth.
It can be difficult to tell when a person is full if they have dementia or other communication deficits. When they stop taking in food
during a meal and seem full, a good practice is to hold each type of food to their lips one more time to be sure they have had all
they want to eat of each food choice. Do the same with fluids.
Documenting food and fluid intake is the same as is required for any resident, but if intake is very minimal, report this to the nurse.
When a person exhibits changes in their appetite, is coughing or clearing their throat more frequently, or has trouble managing
utensils, report these changes to the nurse so that a speech or occupational therapist can assess the resident. Check the dietary card
or care plan so any assistive feeding devices can be utilized to keep the resident as independent as possible and interested in meals.

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10.7: Caregiver Role Strain
Eighty-three percent of the assistance provided to people living with dementia in their homes in the United States comes from
family members, friends, or other unpaid caregivers. Approximately one quarter of dementia caregivers are also “sandwich
generation” caregivers, meaning that they are not only caring for an aging parent, but also providing care for children under age 18.
Because of the 24/7 care required, caring for a loved one with dementia can take a devastating toll on caregivers. Compared with
other caregivers for people without dementia, twice as many caregivers for people with dementia indicate substantial emotional,
[1] [2]
financial, and physical difficulties. See Figure 10.9 of an image of a caregiver daughter caring for her mother with dementia.

Figure 10.9 Daughter Caregiver

[3]
Signs of caregiver role strain for family caregivers may include these behaviors or thoughts :
Denial about the disease and its effect on the person who has been diagnosed. For example, the caregiver might say, “I know
Mom is going to get better.”
Anxiety about the future and facing another day. For example, the caregiver might say, “What happens when he needs more
care than I can provide?”
Sleeplessness caused by concerns. For example, the caregiver might say, “What if she wanders out of the house or falls and
hurts herself?”
Difficulties at work especially if the need for time off impact their job duties or the stress and fatigue from caregiving
compromise their performance.
Changes in relationships and roles. Some people find it challenging to assume responsibility for a family member’s needs as a
caregiver while still in the role of a spouse or a daughter/son. These feelings can cause additional feelings of stress and grief.
[4]
Signs of caregiver role strain for family or paid caregivers may include the following :
Anger at the person with dementia or frustration that they can’t do the things they used to be able to do. For example, the
caregiver might say, “He knows how to get dressed; he’s just being stubborn.”
Social withdrawal from friends and activities. For example, the caregiver may say, “I don’t care about visiting with my friends
anymore.”
Depression or decreased ability to cope. For example, the caregiver might say, “I just don’t care anymore.”
Exhaustion that makes it difficult for them to complete necessary daily tasks. For example, the caregiver might say, “I’m too
tired to prepare meals.”
Irritability, moodiness, or negative responses.
Lack of concentration that makes it difficult to perform familiar tasks. For example, the caregiver might say, “I was so busy; I
forgot my appointment.”
Health problems that begin to take a mental and physical toll. For example, the caregiver might say, “I can’t remember the last
time I felt good.”
There are resources available to assist home caregivers with dependent family members such as adult day care, respite care, or
hospice care. Adult day centers offer people with dementia, developmental disorders, and other chronic mental health illnesses the
opportunity to be social and to participate in activities in a safe environment, while also giving their caregivers the opportunity to
work, run errands, or take a break. Respite care can be provided at home (by a volunteer or paid service) or in a care setting, such
as adult day care or residential facility, to provide the caregiver a much-needed break. If the person with Alzheimer’s or other

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dementia prefers a communal living environment or requires more care than can be safely provided at home, a residential facility
such as assisted living or long-term care may be the best option for meeting the individual’s needs. Different types of facilities
[5]
provide different levels of care, depending on the person’s needs. These varying levels were presented in the Chapter 2.6, “Health
Care Settings” section.
Caregiver role strain can also occur when health care providers feel overwhelmed or unable to appropriately provide the care
needed to manage the complex holistic needs of patients dependent upon them for their care. It can also be caused by working
extended shifts, working several days in a row without time off, or from the daily repetition of managing clients with high care
needs.
It may be difficult for you as a caregiver to recognize when you are feeling overwhelmed by the responsibility for providing care to
many dependent people with high care needs. Although this is the foundation of being a competent and dependable caregiver,
providing care when you are not at your best can be unsafe for both you and those you care for. Feelings of stress overload related
to client care should be communicated with your supervisor. Working while experiencing these feelings can result in poor decision-
making and possibly result in negligence in your care. Here are some things to do to help manage your work responsibilities and
stay healthy:
Get adequate sleep
Eat a nutritious diet
Get regular physical activity
Rotate shifts, units, or clients as able
Talk with a trusted support person or professional while following HIPAA guidelines
Take time off as able
Practice mindfulness, meditation, or yoga
Get a massage
Engage in enjoyable leisure activities
Just as you would report a change in behavior for a resident, you should treat yourself in the same manner. Knowing when you
need a break or additional assistance is a responsible and professional action. As a coworker, recognize when other staff are
experiencing caregiver role strain and offer assistance so they can take a break.

1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
2. “My_mum_ill_with_dementia_with_me.png” by MariaMagdalens is licensed under CC BY-SA 4.0 ↵
3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵
5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵

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10.8: Learning Activities

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10.9: X Glossary
Adaptive behavior: The skills and abilities to live independently.
Agnosia: The failure to recognize or identify objects despite intact sensory function.
Anxiety: A universal human experience that includes feelings of apprehension, uneasiness, uncertainty, or dread resulting from a
real or perceived threat.
Anxiety disorder: A condition diagnosed when an individual experiences more than temporary worry or fear that interferes with
their daily functioning.
Apraxia: The impaired ability to carry out motor activities despite intact motor function. This means the person can understand
instructions and has the ability to complete an action but cannot process the cue to actually perform the task.
Bipolar disorder: A condition that includes shifts in mood from abnormal highs (called manic episodes) to abnormal lows (i.e.,
depressive episodes) that cause significant impairment on the person’s functioning socially or at work.
Delirium: Psychosis caused by medical conditions or substance use that starts suddenly and is reversible by treating the cause of
the delirium.
Delusions: Fixed, false beliefs held by a person even though there is concrete evidence they are not true.
Dementia: A general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to
interfere with daily life. There are several types of dementia, including Alzheimer’s disease, vascular dementia, Lewy body
dementia, and frontotemporal dementia.
Depressive episode: A condition where the person experiences a depressed mood (feeling sad, irritable, or empty) or a loss of
pleasure or interest in activities they normally enjoy. Other symptoms may include poor concentration, feelings of excessive guilt
or low self-worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight,
and feeling especially tired.
Developmental disorders: Disorders caused by impairments in the brain or central nervous system due to problems that occurred
during fetal development.
Hallucinations: A symptom of psychosis when someone perceives seeing, hearing, feeling, tasting, or smelling something that is
not actually present. Some people are aware that their hallucinations are not real while others cannot separate their hallucinations
from reality.
Manic episode: An elevated or irritable mood with abnormally increased energy that lasts at least one week.
Obstructive sleep apnea: A condition where one’s breathing temporarily stops while sleeping.
Panic attacks: Sudden periods of intense fear that come on quickly and reach their peak within minutes. Attacks can occur
unexpectedly or can be brought on by a trigger, such as a feared object or situation. People experiencing a panic attack may exhibit
symptoms such as sweating, trembling, shortness of breath, chest pain, nausea, increased heart rate, or feelings of losing control.
Perseverating: The act of repeating a task or thought over and over.
Personality disorder: A pattern of inner experiences and behaviors that deviates from the expectations of the individual’s culture.
Phobia: An intense fear of specific objects or situations (such as flying, heights, spiders, or social events).
Pocketing: The act of keeping food or medications in one’s cheeks and not swallowing it.
Psychosis: Conditions when a person experiences a loss of contact with reality and has difficulty understanding what is real and
what is not real. Symptoms of psychosis include hallucinations and delusions.
Substance use disorder (SUD): An illness caused by the repeated misuse of substances such as alcohol, caffeine, cannabis,
hallucinogens, inhalants, opioids, sedatives, stimulants, or misuse of other prescription or over-the-counter medications. All these
substances taken in excess have a common effect of intensely activating the reward system in the brain so much that normal life
activities may be neglected.
Sundowning: Restlessness, agitation, irritability, or confusion that typically begins or worsens as daylight begins to fade and can
continue into the night, making it difficult for patients with dementia to sleep.

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Trauma: An event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally
harmful or life-threatening and can have lasting adverse effects on their functioning and mental, physical, social, emotional, or
spiritual well-being.
Trisomy: A condition of having an extra copy of a chromosome.
Validation therapy: A technique used when caring with individuals with dementia that involves supporting the reality the person
is experiencing.
Wandering: The simple act of a person walking around with no purpose due to their confusion regarding their location or
environment.

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 CHAPTER OVERVIEW

11: Apply Knowledge of Body Systems to Client Care

11.1: Introduction to Apply Knowledge of Body Systems to Client Care
11.2: Cardiovascular System
11.3: Digestive System
11.4: Endocrine System
11.5: Integumentary System
11.6: Musculoskeletal System
11.7: Urinary System
11.8: Neurological System
11.9: Immune System
11.10: Respiratory System
11.11: Reproductive System
11.12: Learning Activities
11.13: XI Glossary

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is available upon request.

1
11.1: Introduction to Apply Knowledge of Body Systems to Client Care
Learning Objectives
Apply basic knowledge of body systems to specialize care for chronic conditions
Promote healthy outcomes for individuals with compromised bodily functions
Identify signs and symptoms that should be reported to the supervising nurse
Provide interventions for chronic conditions within the scope of practice for nursing assistants

In this chapter you will learn the basic structure and functions of body systems and apply this knowledge to the individuals for
whom you provide care. Age-related changes and common chronic conditions in each body system are outlined with related
nursing assistant interventions to promote optimal patient outcomes. Observations related to each condition are discussed, as well
as what should be immediately reported to the nurse.

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11.2: Cardiovascular System
[1]
The cardiovascular system consists of the heart, blood, and blood vessels. (See Figure 11.1. ) The heart pumps the blood through
the blood vessels. Blood can be viewed as the transportation fluid that transports nutrients to cells and carries wastes away from
[2]
cells.

Figure 11.1 The Cardiovascular System

The transportation route to all tissues is an intricate blood vessel network composed of arteries, veins, and capillaries. See Figure
[3]
11.2 for an illustration of the blood vessel network. The transportation of nutrients begins in the small intestine where they are
absorbed and then transported to the liver through the hepatic portal vein. From the liver, nutrients travel in the blood up to the
inferior vena cava blood vessel to the heart. The heart pumps the nutrient-rich blood to the lungs to pick up oxygen. The
oxygenated blood returns to the heart, where it is pumped out to tissues in the body through the aorta and the arteries. Arteries
become smaller and smaller on their way to cells, so that by the time blood reaches a cell, the vessel’s diameter is extremely small,
and it is now called a capillary. This reduced diameter of capillaries slows the speed of blood flow and gives cells time to harvest
the nutrients and oxygen in the blood and return metabolic wastes to the capillary to be eliminated. Deoxygenated blood containing
[4]
metabolic wastes is transported back to the heart via veins, and wastes are filtered out by the kidneys and liver.

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 Figure 11.2 Transportation of Nutrients and Elimination of Wastes
As the body ages, the strength and elasticity of the heart and blood vessels decrease, resulting in a decreased ability to regulate
blood pressure, distribute oxygen, and remove wastes from the body. These changes can lead to dizziness (and a higher fall risk),
fluid retention, edema, fatigue, and decreased stamina to complete daily functions.
In addition to these age-related changes, a diet high in saturated fats causes plaque to be deposited on the walls of the blood vessels,
causing further narrowing and decreased blood flow. This decrease in circulation increases the risk for blood clots, heart attacks,
and strokes.
Because the cardiovascular system is vital for health, any symptoms related to chest pain, shortness of breath, or lack of
oxygenation should be immediately reported to the nurse. Cyanosis is a common cardiovascular symptom that refers to bluish
discoloration around the mouth and in the extremities (i.e., feet and hands). It occurs when there is decreased oxygenated blood
flow to the tissues and should be immediately reported to the nurse. Common nursing assistant interventions for all cardiovascular
conditions include encouraging activity as tolerated; promoting a low fat, low cholesterol diet; motivating individuals to quit
smoking; and helping individuals make healthy food choices to maintain a healthy weight. Table 11.2 describes symptoms of
common cardiovascular diagnoses and related nursing assistant interventions.
[5] [6] [7] [8] [9]
, , , ,
Table 11.2 Common Chronic Cardiovascular Diagnoses and Related Nursing Assistant Interventions

Diagnosis Definition Symptoms to Report Specific Interventions

Obtain daily or weekly weights

as prescribed.
Apply TED hose as prescribed.
Apply oxygen as ordered.
Elevate edematous extremities.
Monitor fluid intake and
Heart muscle becomes weakened Increasing edema, shortness of output.
and is unable to adequately pump breath, cyanosis, or rapid weight Implement fluid restrictions as
Heart Failure (HF)
oxygenated, nutrient-rich blood to gain (i.e., more than 2 -3 pounds prescribed.
the tissues. in 24 hours). Seek emergency assistance
from the nurse or in outpatient
settings call 911 for individuals
with sudden chest pain; severe
shortness of breath; or
coughing up white or pink,
foamy mucus.

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 Promote a low sodium diet.
Increased pressure of blood flow Promote stress management
against the arteries. HTN is often activities.
Hypertension (HTN) or High
called the “silent killer” because Dizziness and/or headache. Encourage regular
Blood Pressure
there are few recognizable appointments with health care
symptoms. provider to monitor blood
pressure.

Limit alcohol.
Irregular heart rhythm that can Fatigue, dizziness, chest pain, Promote follow-up
Atrial Fibrillation cause decreased blood pressure, shortness of breath, and/or appointments with health care
blood clots, and strokes. palpitations. provider to monitor heart
rhythm.

Smoking, high blood pressure,

high cholesterol, diabetes,
obesity, or a strong family
history of heart disease
increases the risk for coronary
Signs and symptoms occur when
artery disease. Encourage
the heart muscle doesn’t get
Cholesterol deposits (plaque) in individuals with these
enough oxygen-rich blood,
Coronary Artery Disease (CAD) the heart and arteries cause conditions to seek care from a
causing chest pain and shortness
decreased oxygenated blood flow. health care provider to prevent
of breath. A complete blockage
a heart attack.
can cause a heart attack.
If an individual is experiencing
sudden chest pain or shortness
of breath, obtain emergency
assistance from the nurse or
call 911 in outpatient settings.

Bed rest, lack of movement,

and surgery can cause blood
clots to form. Encourage
movement as tolerated or
perform range of motion
A DVT is a blood clot in a deep
exercises.
vein, typically occurring in the
Apply sequential compression
legs.
devices (SCDs) to post-op
DVT can be serious because blood
patients as prescribed to
clots in the veins can break loose Unilateral leg swelling, redness,
prevent DVT. Do not apply
Deep Vein Thrombosis (DVT) and travel through the warmth, and/or tenderness or calf
SCDs if signs of a DVT are
bloodstream and get stuck in the cramping.
present.
lungs, called a pulmonary
Immediately notify the nurse of
embolism (PE). PEs block
symptoms of a suspected DVT.
oxygenated blood flow and are
Seek emergency assistance or
life-threatening.
call 911 in outpatient settings
for signs of a PE such as
sudden shortness of breath,
chest pain, or coughing up
blood.

1. “Circulatory_System_no_tags.png” by LadyofHats is in the Public Domain ↵

2. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
3. “2101_Blood_Flow_Through_the_Heart.jpg” by OpenStax College is licensed under CC BY 3.0 ↵
4. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵

11.2.3 https://med.libretexts.org/@go/page/70430
 5. Mayo Clinic Staff. (2021, October 19). Atrial fibrillation. https://www.mayoclinic.org/diseases-conditions/atrial-
fibrillation/diagnosis-treatment/drc-20350630 ↵
6. Mayo Clinic Staff. (2021, December 10). Heart failure. https://www.mayoclinic.org/diseases-conditions/heart-
failure/symptoms-causes/syc-20373142 ↵
7. Mayo Clinic Staff. (2021, July 1). High blood pressure (hypertension). https://www.mayoclinic.org/diseases-conditions/high-
blood-pressure/symptoms-causes/syc-20373410 ↵
8. Mayo Clinic Staff. (2022, May 25). Coronary artery disease. https://www.mayoclinic.org/diseases-conditions/coronary-artery-
disease/symptoms-causes/syc-20350613 ↵
9. Mayo Clinic Staff. (2022, June 11). Deep vein thrombosis (DVT). https://www.mayoclinic.org/diseases-conditions/deep-vein-
thrombosis/symptoms-causes/syc-20352557/. ↵

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11.3: Digestive System
There are four steps in the digestive process. The first step is ingestion, the intake of food into the digestive tract. Ingestion may
seem a simple process, but it includes smelling food as it is prepared and served, thinking about food and making food choices, and
the involuntary release of saliva in the mouth to prepare for food entry. After food enters the mouth, the next steps of mechanical
and chemical digestion of food begin. Mechanical digestion starts with chewing when teeth crush and grind large food particles
into smaller pieces that are easy to swallow. Chemical digestion of food involves enzymes found in saliva that break down
[1]
particles into smaller components.
In the mouth, saliva provides lubrication and enables food to move downward through the esophagus (a muscular tube that goes
from the mouth to the stomach). This slippery mass of partially broken-down food is called a bolus that moves down the digestive
tract after it is swallowed. Swallowing is initially voluntary because it requires conscious effort to push the food with the tongue
back towards the throat, but then it proceeds involuntarily through the gastrointestinal tract, meaning it proceeds without conscious
control.
As the bolus is swallowed, it is pushed from the mouth through the pharynx (i.e., throat) and into the esophagus. As the bolus
travels through the pharynx, a small flap called the epiglottis closes to keep food from going into the trachea and down into the
lungs. Peristaltic contractions in the esophagus (referred to as peristalsis) propel the bolus down to the stomach. At the junction
between the esophagus and stomach, there is a sphincter that remains closed until the food bolus approaches. The pressure of the
food bolus stimulates the lower esophageal sphincter to relax and open, causing the food to move from the esophagus into the
stomach. The mechanical digestion of food continues by the muscular contractions of the stomach and small intestine that mash,
[2]
mix, and continue to propel the bolus down the digestive tract.
In the small intestine, nutrients are absorbed from the bolus and then transported throughout the body by the cardiovascular
system. The small intestine is typically 25 to 30 feet in length with a smaller diameter than the large intestine. After passing
through the small intestine, the bolus enters the large intestine. The large intestine is about 8 to 10 feet in length with a larger
diameter than the small intestine. Water is absorbed from the bolus in the large intestine, making it solid and formed. It eventually
[3] [4]
reaches the anus and is expelled as feces. See Figure 11.3 for an illustration of digestion.

Figure 11.3 The Digestive System

[5]
View the following Khan Academy video for an overview of the digestive process : The Digestive System.

As people age, many age-related changes occur in the digestive system. The condition of one’s teeth (referred to as dentition) often
declines during the aging process, resulting in the decreased ability to chew foods with a dense or tough consistency (such as meat
and fibrous vegetables). Production of saliva also decreases, increasing the risk for choking. Additionally, many medications cause
a side effect of dry mouth that further contributes to the risk of choking. The epiglottis may weaken and allow food or fluids to

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enter the lungs that can cause aspiration pneumonia. Absorption of nutrients in the small intestine is less efficient, which can cause
malnutrition even though food intake may be sufficient. Lastly, the slowing of peristalsis allows the bolus to remain in the large
intestine for longer periods of time. As water continues to be absorbed, the fecal matter becomes drier and more difficult to expel,
resulting in constipation and possible bowel obstruction.
A bowel obstruction stops the bolus and other digestive contents from reaching the part of the intestine beyond the blockage. The
lack of peristalsis that occurs during a bowel obstruction can cause the large intestine to twist upon itself, cutting off circulation and
causing tissue death. The area of the intestine experiencing tissue death may require surgical removal. Sometimes the remaining
parts of the healthy intestine can be reattached to regain normal bowel function. However, if reattachment is not possible, an
opening (called a stoma) is surgically created in the abdominal wall where the healthy part of the intestine is attached. (This type of
surgery to create a stoma in the colon is referred to as a colostomy.) Fecal matter is collected in a drainage bag that attaches to the
stoma via a device commonly called a wafer. In this manner, elimination occurs through the stoma into a pouch rather than through
the rectum. Bowel obstructions, as well as other gastrointestinal conditions such as colon cancer, severe infection, fistulas, or colon
[6]
injuries, can lead to the placement of a stoma. See Figure 11.4 for an image of a stoma, Figure 11.5 for an image of the wafer to
[7]
which the drainage bag attaches, and Figure 11.6 for an image of an attached drainage bag.

Figure 11.4 Stoma

Figure 11.5 Stoma With a Wafer Placed to Attach the Drainage Bag

Figure 11.6 Drainage Bag Attached to a Wafer

The most effective interventions for improving digestive function are to encourage intake of fiber, water, and other fluids, as well
as promoting activity as tolerated. Fiber adds bulk to the bolus to keep it moving through the large intestine. Fiber is found in
plants, so any food that originates from growing in the ground contains fiber. Examples of high-fiber foods include grains in bread
and cereal, rice, barley, quinoa, fruits, and vegetables. Whole grains are preferred because they contain more fiber than processed
grains. Water and other fluids aid in peristaltic movement, and activity increases circulation to improve digestive function. See
Table 11.3 for common digestive system diagnoses, associated symptoms to report to the nurse, and specific interventions the
nursing assistant can implement to promote digestive function. Refer to section Chapter 5.7, “Assisting With Nutrition and Fluid
Needs” for additional review of digestive interventions.
[8] [9] [10] [11] [12]

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 [8],[9],[10],[11],[12]
Table 11.3 Common Digestive System Diagnoses and Specific Nursing Assistant Interventions

Diagnosis Definition Symptoms to Report Nursing Assistant Interventions

Apply topical hemorrhoid

cream to reduce pain as
ordered.
Bleeding during bowel Gently cleanse anal area.
movements should be reported to Discourage sitting for long
Swollen vein(s) in the rectum and the nurse for follow-up. periods of time, especially on
anus caused by straining from If a hemorrhoid becomes the toilet.
Hemorrhoids constipation, during childbirth, or strangulated or a clot forms in a Encourage use of the bathroom
from regular heavy lifting. Risk hemorrhoid, it can cause severe as soon as the urge is felt to
increases with aging. pain, swelling, inflammation, or a have a bowel movement.
hard lump near the anus and Seek emergency assistance for
should be immediately reported. large amounts of rectal
bleeding or associated light-
headedness, dizziness, or
faintness.

Avoid foods that trigger an

A chronic disorder causing
individual’s symptoms.
cramping, abdominal pain,
Avoid gas-producing foods like
bloating, gas, diarrhea, and
Irritable Bowel Syndrome (IBS) Increased symptoms. broccoli and cauliflower.
constipation. Symptoms may be
Report a change in bowel
triggered by stress or specific
habits or rectal bleeding to the
foods.
nurse.

Avoid eating large meals or

eating late at night.
Avoid foods that trigger
symptoms, such as fatty or
fried foods, tomato sauce,
alcohol, chocolate, mint, garlic,
onion, and caffeine.
Avoid beverages that trigger
Stomach acid flows back into the Burning sensation in chest,
Gastroesophageal Reflux Disease symptoms, such as alcohol or
esophagus, causing symptoms regurgitation of food or sour
(GERD) coffee.
often referred to as “heartburn.” liquid, or chronic cough.
Encourage quitting smoking.
Discourage lying down after a
meal.
Elevate the head of the bed 6 to
9 inches.
Avoid wearing tight-fitting
clothing that puts pressure on
the abdomen.

Avoid trigger foods.

For lactose intolerance,
lactose-reduced dairy products
An inability to digest specific
may be eaten, or a lactase
foods. Common food intolerances Increased gas, bloating, diarrhea,
Food Intolerance enzyme may be added to milk
are lactose intolerance (dairy) or and abdominal cramping.
to break down the lactose.
gluten intolerance (wheat).
For gluten intolerance, oat,
rice, or corn products may be
substituted for wheat.

11.3.3 https://med.libretexts.org/@go/page/70431
 Check the client’s dietary
orders before serving meal
trays and ensure correct foods
are provided. Common food
An immune system reaction to a Immediately report hives (a new allergies include shellfish,
Food Allergies specific food that can range from rash); swelling of the lips, tongue, peanuts, and eggs.
mild to life-threatening. or throat; or problems breathing. Severe food allergies can cause
anaphylaxis, a life-threatening
reaction that blocks breathing
and requires emergency
assistance.

1. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
2. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
3. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
4. “Digestive-system-overview.jpg” by Allison Calabrese is licensed under CC BY 4.0. Access for free at
https://pressbooks.oer.hawaii.edu/humannutrition/chapter/the-digestive-system-2/ ↵
5. Khan Academy. (n.d.). The digestive system [Video]. Khan Academy. All rights reserved.
https://www.khanacademy.org/science/biology/crash-course-bio-ecology/crash-course-biology-science/v/crash-course-biology-
127 ↵
6. “Ostomy_wafer_being_worn_by_an_ileostomy_patient.jpg” by Eric Polsinelli (VeganOstomy) is licensed under CC BY 4.0 ↵
7. “Ileostomy_2016-09-09_4158.jpg” by Salicyna is licensed under CC BY-SA 4.0 ↵
8. Mayo Clinic Staff. (2021, May 12). Hemorrhoids. https://www.mayoclinic.org/diseases-conditions/hemorrhoids/symptoms-
causes/syc-20360268 ↵
9. Mayo Clinic Staff. (2021, December 1). Irritable bowel syndrome. https://www.mayoclinic.org/diseases-conditions/irritable-
bowel-syndrome/symptoms-causes/syc-20360016 ↵
10. Mayo Clinic Staff. (2020, May 22). Gastroesophageal reflux disease (GERD). https://www.mayoclinic.org/diseases-
conditions/gerd/symptoms-causes/syc-20361940 ↵
11. Mayo Clinic Staff. (2022, March 5). Lactose intolerance. https://www.mayoclinic.org/diseases-conditions/lactose-
intolerance/symptoms-causes/syc-20374232 ↵
12. Mayo Clinic Staff. (2022, June 16). Milk allergy. https://www.mayoclinic.org/diseases-conditions/milk-allergy/symptoms-
causes/syc-20375101 ↵

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11.4: Endocrine System
Endocrine glands secrete hormones that affect the functioning of other organs throughout the body and are transported by the
circulatory system. The glands in the endocrine system are the pituitary, thyroid, parathyroid, adrenals, thymus, pineal, pancreas,
[1]
ovaries, and testes, as seen in Figure 11.7.

Figure 11.7 The Endocrine System

The functions of the endocrine system are connected to an individual’s nutrition. The endocrine system is responsible for regulating
appetite, nutrient absorption, nutrient storage, and nutrient usage, as well as contributing to other body functions such as
reproduction. The most notable connection between nutrition and the functions of the endocrine system is how unhealthy dietary
[2]
patterns are linked to obesity and the development of diabetes.
The pancreas is an endocrine gland that makes insulin, the hormone that allows cells to use glucose for energy. Insulin is released
after an individual eats a meal based on the amount of calories they consumed. The function of the pancreas is affected by a
medical condition called diabetes. The Centers for Disease Control and Prevention (CDC) estimates that 11 percent of the U.S.
[3]
population has diabetes, and 49 percent of adults over age 65 have prediabetes.

See maps of diabetes and obesity by county at CDC’s Diabetes and Obesity Maps web page.

In type 1 diabetes, the pancreas becomes unable to make insulin. In type 2 diabetes, obesity causes changes in muscle, fat, and liver
cells that leads to their diminished response to insulin, referred to as “insulin-resistance.” When cells are resistant to insulin, they
do not take in enough glucose to make energy, resulting in high levels of glucose in the blood. Chronically elevated blood glucose
damages other tissues over time, increasing the individual’s risk for cardiovascular disease, kidney disease, nerve damage, and eye
[4]
disease. The nerve damage causes pain and numbness in the feet and lower legs that can increase risk for falls.
Individuals with diabetes must frequently measure their blood glucose level to keep it in normal range with medications prescribed
by their health care provider. Blood glucose levels are typically checked in individuals with diabetes from one to four times per
day. This measurement is typically performed by the nurse, but some states allow nursing assistants to receive additional training to
complete this procedure.
People with diabetes are typically prescribed oral medications or injectable insulin to keep their blood glucose in a healthy range.
Too much or not enough insulin can cause life-threatening reactions so it must be administered cautiously. In hospitals and long-
term care centers, insulin is administered by a nurse.
Too much insulin or not enough carbohydrate intake results in very low blood sugar (referred to as hypoglycemia) that can cause a
coma if it is not quickly addressed. Nursing assistants must observe for signs of low blood sugar in clients with diabetes and
immediately report them to the nurse for follow-up. Signs of low blood sugar include confusion, irritability, shakiness, cold and
[5]
clammy skin, sweating, hunger, and anxiety.

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When not enough insulin or other diabetic medications are administered for the amount of carbohydrates an individual consumes,
blood glucose levels become elevated (i.e., hyperglycemia). Symptoms of elevated blood glucose include increased urination;
increased thirst and hunger; a fruity breath odor; warm, dry skin; and fast, deep breathing. These symptoms should be immediately
[6]
reported to the nurse.
Because nutritional intake affects an individual’s blood glucose, nursing assistants play a helpful role in encouraging healthy diet
choices for individuals with diabetes. Encourage clients to avoid eating refined sugar and highly processed foods and increase their
intake of whole grains and non-starchy vegetables such as broccoli, spinach, and green beans. Encouraging residents to be as active
[7]
as possible can also help manage their blood glucose levels.
If neuropathy occurs, the individual’s skin should be diligently inspected daily, especially on the bottoms of their feet and in
between their toes. Well-fitted shoes should be worn, and socks should be carefully placed so the seams do not cause irritation.
Individuals with neuropathy do not feel skin irritations or open areas, and they can become infected quickly. If left untreated,
severe infection can lead to amputation. Due to these risks, nursing assistants should not trim the nails of diabetic patients.

1. “llu_endocrine_system_New.png” by US Government is in the Public Domain ↵

2. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
3. Centers for Disease Control and Prevention. (2022, March 9). Diabetes data and statistics.
https://www.cdc.gov/diabetes/data/index.html ↵
4. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
5. Centers for Disease Control and Prevention. (2022, June 1). Diabetes. https://www.cdc.gov/diabetes/index.html ↵
6. Centers for Disease Control and Prevention. (2022, June 1). Diabetes. https://www.cdc.gov/diabetes/index.html ↵
7. Centers for Disease Control and Prevention. (2022, June 1). Diabetes. https://www.cdc.gov/diabetes/index.html ↵

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11.5: Integumentary System
Review information about the integumentary system in Chapter 5.5, “Skin Care” and Chapter 8.2, “Moving and Positioning
Clients.” These sections can be reviewed for age-related changes and interventions to promote skin integrity.

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11.6: Musculoskeletal System
The musculoskeletal system includes muscles, bones, and connective tissues. The human skeleton consists of 206 bones and other connective tissues called ligaments,
[1]
tendons, and cartilage. See Figure 11.8 for an illustration of the major bones of the body. Ligaments connect bones to other bones, tendons connect bones to muscles,
and cartilage provides bones with flexibility and acts as a cushion in the joints between bones.

Figure 11.8 Major Bones of the Body

The skeleton’s bones and connective tissues work together with muscles to provide a variety of functions and multiple types of movements. Gross motor skills are large
movements controlled by the legs and trunk of the body. Fine motor skills are small movements such as those by the wrists and hands. The skeleton also provides
structural support and protection for all the other organ systems in the body. The skull, or cranium, is like a helmet and protects the eyes, ears, and brain. The ribs form a
[2]
cage that surrounds and protects the lungs and heart.
In addition to producing movement, protecting organs, and providing structural support, the bones have several other functions. Bone marrow synthesizes red blood cells,
white blood cells, and platelets, and bones store minerals such as calcium, phosphorus, and magnesium. Although bone tissue may look inactive at first glance, bones are
continuously breaking down and reforming at the microscopic level. Bones also contain a complex network of canals, blood vessels, and nerves that allow for nutrient
[3]
transport and communication with other organ systems.
There are three types of muscle tissue, including skeletal muscle, cardiac muscle, and smooth muscle. Skeletal muscle produces movement, assists in maintaining
posture, protects internal organs, and generates body heat. Skeletal muscles are voluntary, meaning a person is able to consciously control them, but they also depend on
[4]
signals from the nervous system to work properly. See Figure 11.9 for an illustration of skeletal muscle. To move the skeleton, the tension created by the contraction of
[5]
the skeletal muscles is transferred to the tendons, strong bands of dense, regular connective tissue that connect muscles to bones.

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 Figure 11.9 Major Muscles of the Body
Other types of muscles are involuntary and are controlled by the autonomic nervous system. Involuntary muscle includes the smooth muscle within the digestive system
[6]
and respiratory system, as well as cardiac muscle in the heart that pumps blood throughout the body.
Review sections Chapter 8.3, “Promoting Joint Mobility and Activity,” Chapter 9.4, “Complications of Immobility,” and Chapter 9.6, “Promoting Independence During
ADLs” regarding problems that may occur in the musculoskeletal system, as well as how to assist clients in keeping the musculoskeletal system healthy. Remember that
clients maintain range of motion, flexibility, and bone health by being as active as possible, especially with weight-bearing activity. Nursing assistants should promote
ambulation as tolerated and encourage clients to move about independently as much as possible. Nursing assistants can also encourage protein diet choices to assist with
tissue growth and repair and calcium to assist with bone health. Lean protein, such as low-fat meats and dairy products, are examples of healthy protein choices. Dairy
[7]
products, soy milk, almond milk, and coconut milk are good sources of calcium, as well as green leafy vegetables like spinach, kale, and romaine.
A common condition in the musculoskeletal system is osteoarthritis, a medical diagnosis that refers to inflammation of joints due to wear and tear throughout one’s life.
Interventions that nursing assistants can perform to help alleviate discomfort associated with osteoarthritis are discussed in section Chapter 6.4, “Comfort Measures” and
include measures such as ice, heat, topical medications, repositioning, and massage. Effectiveness of measures will vary by individual, so it is important to allow each
individual to choose what is most helpful to alleviate their arthritis.

1. “701 Axial Skeleton-01.jpg” by OpenStax is licensed under CC BY 3.0 ↵

2. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed under CC BY NC SA
4.0 ↵
3. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed under CC BY NC SA
4.0 ↵
4. “1105 Anterior and Posterior Views of Muscles.jpg” by OpenStax is licensed under CC BY-SA 4.0 ↵
5. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed under CC BY NC SA
4.0 ↵
6. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed under CC BY NC SA
4.0 ↵
7. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed under CC BY NC SA
4.0 ↵

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This page titled 11.6: Musculoskeletal System is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra Sandquist Reuter via source content that was edited
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11.7: Urinary System
The urinary system includes the kidneys, ureters, bladder, and urethra. It has many functions including filtering the blood and
eliminating wastes, regulating blood and urine pH levels, and working in collaboration with the cardiovascular system to regulate
blood pressure. The urinary system also provides reproductive functions in the prostate for males. The kidneys also release a
hormone that stimulates red blood cell production and synthesizes vitamin D to assist in bone health. Each of these functions is
[1] [2]
vital to well-being and survival. See Figure 11.10 for an illustration of the structures of the urinary system.

Figure 11.10 The Urinary System

Blood is filtered through the kidneys, and the filtrate is transformed into urine at a relatively constant rate throughout the day. The
urine travels from the kidneys through the ureters to the bladder. The bladder stores urine and signals the brain when full (around
300 mL). It stores urine until a convenient time for elimination or voiding, and then the brain allows the urethra to release the urine.
[3]

Urine is a fluid of variable composition. Urine characteristics change depending on influences such as water intake, exercise,
environmental temperature, nutrient intake, and other factors. Characteristics such as color and odor provide a rough estimate of a
person’s state of hydration. For example, after exercising or working outside on a hot day and sweating heavily, urine will become
[4] [5]
darker with a slight odor. See Figure 11.11 for ranges of urinary color related to hydration status. Review the subsection
“Observation and Documentation of Urinary Output” in Chapter 5.8 for other characteristics that nursing assistants should
document when assisting clients to void.

Figure 11.11 Urine Color Related to Hydration Status

Urine volume varies considerably. The normal range of urine output for an adult is one to two liters per day. The kidneys must
produce a minimum urine volume of about 500 mL/day to adequately eliminate wastes from the body. Output below this level can
[6]
be caused by severe dehydration or kidney disease.

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The effects of failure of various parts of the urinary system can range from incontinence to kidney disease with a life-threatening
loss of the ability to eliminate wastes. When the kidneys begin to fail, several symptoms may occur such as weakness, shortness of
[7]
breath, widespread edema (swelling), rising potassium levels, and heart arrhythmias.
Failure of voluntary control of urination is called incontinence. Incontinence may occur if the connection between the brain and
the urethra is disrupted or there is loss of muscle tone in the urinary system. There are several types of incontinence. Incontinence
in small amounts (i.e., leaking or dribbling) can occur from coughing, laughing, or moving when the bladder is full. Some people
feel an urge to void and then must go immediately or incontinence may occur if they are not near a restroom. Some people have
[8]
total loss of control of urination, resulting in the entire contents of their bladder being released involuntarily. Refer to section
Chapter 5.8, “Assisting With Toileting” to review appropriate interventions to help prevent incontinence.
The prostate gland encompasses the urethra in males. As males age, the prostate gland grows, known as benign prostate
enlargement (BPE). Because prostate enlargement puts pressure on the urethra, the urine may become blocked. Older men may
experience difficulty starting the stream of urine or become unable to completely empty their bladder. If the blockage becomes
significant, it can cause infection when urine remains in the bladder for long periods of time. In these cases, a urinary catheter may
be placed to reduce the retention of urine, or a surgical procedure may be completed to reopen the urethra.
See Table 11.7 for common chronic conditions, symptoms to report, and interventions nursing assistants can provide to promote
urinary health.
[9] [10] [11] [12]
, , ,
Table 11.7 Common Chronic Conditions of the Urinary System and Related Interventions

Diagnosis Definition Symptoms to Report Nursing Assistant Interventions

Implement a toileting schedule.

Prompt residents to void before
they feel the urge to do so.
If the client is unable to
Inability to control the elimination Change in the frequency or
Urinary Incontinence communicate the need to void,
of urine. amount of incontinence.
check their incontinence
product at least every two
hours to keep the skin dry and
free of breakdown.

Increased frequency of voiding;

Provide good perineal hygiene.
pain, itching, or burning with
Implement a toileting schedule.
voiding; voiding in small
Encourage fluids for good
Infection of any part of the urinary amounts; strong odor; dark or
Urinary Tract Infection (UTI) hydration as appropriate.
system. cloudy urine; and/or sediment or
Assist with activity as
blood in the urine. A sudden
tolerated.
increase in confusion can also
Wipe from front to back.
indicate infection.

Encourage fluids as
Deposits of minerals from appropriate.
Increased pain in the abdomen or
Kidney Stones concentrated urine that form a Promote activity as tolerated.
pain with voiding.
mass in the kidneys. Encourage prescribed diet to
prevent formation of stones.

11.7.2 https://med.libretexts.org/@go/page/70435
 Encourage prescribed renal diet
(decreased amounts of sodium,
potassium, protein, and
phosphorus).
Follow prescribed fluid
restrictions and provide
Puffiness around the eyes, comfort measures for
Kidneys are unable to adequately
frequent urge to urinate, urination associated dry mouth such as
Chronic Kidney Failure filter and remove wastes and
in increasingly smaller amounts, hard candy, ice chips, or breath
fluids from the body.
dry and itchy skin, and/or fatigue. spray.
Encourage quitting smoking.
Assist in maintaining healthy
blood glucose levels in people
with diabetes.
Encourage physical activity as
tolerated.

1. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
2. “llu_urinary_system.svg” by Thstehle is in the Public Domain ↵
3. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
4. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
5. “2601_Urine_Color_Chart.jpg” by OpenStax College is licensed under CC BY 3.0 ↵
6. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
7. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
8. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
9. Mayo Clinic Staff. (2021, December 17). Urinary incontinence. https://www.mayoclinic.org/diseases-conditions/urinary-
incontinence/symptoms-causes/syc-20352808 ↵
10. Mayo Clinic Staff. (2021, April 23). Urinary tract infection (UTI). https://www.mayoclinic.org/diseases-conditions/urinary-
tract-infection/symptoms-causes/syc-20353447 ↵
11. Mayo Clinic Staff. (2022, June 3). Kidney stones. https://www.mayoclinic.org/diseases-conditions/kidney-stones/symptoms-
causes/syc-20355755 ↵
12. Mayo Clinic Staff. (2021, September 3). Chronic kidney disease. https://www.mayoclinic.org/diseases-conditions/chronic-
kidney-disease/symptoms-causes/syc-20354521 ↵

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11.8: Neurological System
[1]
The central nervous system consists of the brain, spinal cord, and other nerves in the body as seen in Figure 11.12. The main
function of the central nervous system is to utilize the senses of sight, touch, hearing, taste, and smell to detect changes in the
external environment and create a reaction to them. For instance, if your finger comes into contact with a thorn on a rose bush, a
sensory neuron transmits a signal from your finger up through the spinal cord and into the brain. Another neuron in the brain sends
a signal that travels back to the muscles in your hand and stimulates muscles to contract so that you jerk your finger away. All this
happens within a tenth of a second. Nerves communicate with each other via chemicals built from amino acids called
neurotransmitters. Eating adequate protein from a variety of sources will ensure the body gets all the different amino acids that
[2]
are important for central nervous system function.

Figure 11.12 The Central Nervous System

The brain’s cognitive functions include language processing, learning, perceiving, and thinking. The brain’s main fuel for these
functions is glucose. Too high or too low levels of blood glucose can cause sudden changes in cognitive functioning, and
chronically elevated blood-glucose levels can damage brain cells as previously discussed in the “Endocrine System” section of this
chapter.
As people age, the transmission of neurons slows, causing slower reactions to environmental stimuli. This longer reaction time can
increase their risk for falls and other safety concerns. Functioning of the senses also declines, as previously discussed in section
Chapter 9.7, “Assisting With Sensory Deficits.” Nursing assistants can assist with this general decline and improve safety by
ensuring residents have their glasses, hearing aids, and other adaptive aids in place. Healthy nutritional choices such as foods rich
in omega-3 fatty acids and antioxidants can be encouraged to keep the neurosensory system healthy, and activity can be promoted.
Having conversations with residents and promoting social interaction whenever possible is one of the easiest ways to encourage
word recall and stimulate thinking. Assisting residents to attend activity department offerings, such as board, card, and word
[3]
games, or looking at memorabilia can help clients maintain their neurological health.
Common conditions related to the neurosensory system include strokes, seizures, and dementia. Refer to section Chapter 3.2,
“Emergency Situations” to review the appropriate responses for individuals suspected of having a stroke or seizure. Refer to
section Chapter 10.5, “Caring for Clients With Dementia” to review interventions for individuals with dementia. See Table 11.8

11.8.1 https://med.libretexts.org/@go/page/70436
regarding two common chronic conditions of the neurosensory system and related nursing assistant interventions. Keep in mind
that a difficult aspect of these neurological diagnoses is knowing that symptoms will continue to worsen, so individuals with these
diagnoses and their loved ones should be supported emotionally and monitored for signs of depression.
[4] [5]
Table 11.8 Common Chronic Conditions of the Neurosensory System and Related Interventions ,

Diagnosis Definition Symptoms to Report Nursing Assistant Interventions

Monitor safety and fall risk.

Decreased production of Keep assistive devices within
dopamine that causes slowed reach.
Changes in strength, gait,
Parkinson’s Disease movement, impaired coordination Allow more time to complete
mobility, or cognition.
and balance, tremors, and speech ADLs.
difficulties. Encourage physical activity as
tolerated.

Encourage healthy diet choices

that are easy to swallow.
Decline in nerve cell function Promote activity as tolerated.
results in progressive muscle Assist with prescribed
Amyotrophic Lateral Sclerosis weakness. Loss of movement Increased difficulty breathing, stretching activities.
(ALS or Lou Gehrig’s Disease) begins in extremities with swallowing, or speaking. Assist with prescribed mobility
eventual death from loss of equipment to remain as
function of respiratory muscles. independent as possible.
Provide emotional support as
needed.

1. “Nervous system diagram.png ” by unknown is licensed under CC BY-NC-SA 3.0. Access for free at
https://med.libretexts.org/Bookshelves/Nursing/Book%3A_Clinical_Procedures_for_Safer_Patient_Care_(Doyle_and_McCutc
heon)/02%3A_Patient_Assessment/2.07%3A_Focused_Assessments ↵
2. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
3. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program
and is licensed under CC BY NC SA 4.0 ↵
4. Mayo Clinic Staff. (2022, March 24). Parkinson’s disease. https://www.mayoclinic.org/diseases-conditions/parkinsons-
disease/symptoms-causes/syc-20376055 ↵
5. Mayo Clinic Staff. (2022, February 22). Amyotrophic lateral sclerosis (ALS). https://www.mayoclinic.org/diseases-
conditions/amyotrophic-lateral-sclerosis/symptoms-causes/syc-20354022 ↵

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11.9: Immune System
[1]
See Figure 11.13 to review the various structures of the immune system. The immune system provides specific and nonspecific defense
mechanisms to protect the body from infection. Examples of a specific defense are white blood cells that circulate in the blood and lymph. The
function of these cells is to identify and destroy pathogens such as bacteria and viruses. Examples of nonspecific defenses are the skin and mucous
membranes. These parts of the system act as barriers to block entrance of pathogens. For more information, refer to the “Defenses Against
Transmission of Infection” section in Chapter 4.

Figure 11.13 Structures of the Immune System

Immune system function and decreasing the risk for infection depends on healthy nutrition. In fact, malnutrition is the leading cause of immune
system deficiency worldwide. When immune system functions are inadequate, there is a marked increase in the chance of getting an infection.
Children in many poor, developing countries who lack good sources of protein and carbohydrates often die from infections that their bodies would
have normally fought off with proper nutritional intake. Because their protein and/or energy intake is so low, the immune system cannot perform
[2]
its functions.
Other nutrients, such as iron, zinc, selenium, copper, folate, and vitamins A, B6, C, D, and E, benefit immune system function. It is best to obtain
minerals and vitamins from eating a variety of healthy foods. Deficiencies in these nutrients can cause an increased risk for infection and even
death. Zinc deficiency results in suppression of the immune system’s skin barrier functions and is also associated with a decrease in the number of
circulating white blood cells. Taking zinc supplements has been found to be therapeutically beneficial for the treatment of leprosy, tuberculosis,
[3]
pneumonia, and the common cold.
Just as undernutrition compromises immune system health, so can overnutrition that causes obesity. People who are obese are at increased risk for
developing diabetes, cardiovascular, and immune system disorders. High intake of saturated and trans fats negatively affects the immune system,
whereas increasing intake of omega-3 fatty acids (found in salmon and other oily fish) reduces the risk of developing certain autoimmune
disorders, such as rheumatoid arthritis. Rheumatoid arthritis affects the joints but is more severe in terms of pain and swelling than osteoarthritis.
It can begin as early as age 18. Nursing assistant interventions for osteoarthritis also can be used to help manage the discomfort of rheumatoid
[4]
arthritis.
Autoimmune disorders cause the body to view parts of itself as foreign, mistake those parts as pathogens, and launch an attack against those parts.
It can affect certain parts of the body like skin, joints, or a specific organ, or it can affect the entire body. In the digestive system, it can cause food
intolerances, celiac disease, or irritable bowel syndrome. Refer to the Chapter 6.2 subsection on “Modified Diets” for management. See Table 11.9
for common chronic conditions and the interventions nursing assistants can provide to assist with immune disorders. Review section Chapter 4.7,
“Signs and Symptoms of Infection” for observations related to the immune system that should be reported to the nurse.
Table 11.9 Common Chronic Conditions of the Immune System and Related Interventions

Diagnosis Definition Symptoms to report Nursing Assistant Interventions

11.9.1 https://med.libretexts.org/@go/page/70437
 Avoid triggers specific to the
Airways become swollen and
affected person.
narrowed in response to an
Increased shortness of breath during Encourage activity as tolerated
Asthma environmental trigger, making it
activity or at rest. between asthma attacks.
difficult to breathe. Severe asthma
Obtain emergency assistance for
attacks can be life-threatening.
severe asthma attacks.

Encourage low-carb and low-fat

diet.
The immune system attacks the Excessive thirst, hunger, or urination; Promote activity as tolerated.
Type 1 Diabetes pancreas and reduces the production of confusion; or hot/dry or cold/clammy Monitor feet and skin condition
insulin. skin. daily and immediately report any
skin breakdown or signs of
infection.

Diligent hand-hygiene and

Leukemia, Lymphoma, and Other Ineffective white blood cells elevate Fatigue, weakness, or signs and
infection control practices.
Immune System Cancers the risk for life-threatening infection. symptoms of infection.
Wear full PPE if indicated.

The virus attacks white blood cells

Diligent hand-hygiene and
Human Immunodeficiency Virus that identify pathogens in the body, Fatigue, weakness, or signs and
infection control practices.
(HIV) and they are no longer able to fight symptoms of infection.
Wear full PPE if indicated.
infection.

As the thyroid is attacked by the Provide warm blankets and socks

immune system, the regulation of for clients with cold intolerance.
Increased fatigue or cold intolerance
Thyroid Disorders hormones that control metabolism, Manage room temperature and
or changes in appetite or mood.
energy levels, body temperature, heart environmental stimulation for
rate, and appetite are affected. clients with heat intolerance.

Manage environmental temperature

The immune system attacks the
as appropriate because it can trigger
protective sheath around the spinal
symptoms.
Multiple Sclerosis (MS) cord, causing disruption of signals Decreased mobility or cognition.
Assist client with ADLs as needed.
from the brain to body parts.
Monitor mobility to reduce safety
Functioning can vary from day-to-day.
and fall risks.

1. “2206_The_Location_Structure_and_Histology_of_the_Thymus.jpg” by OpenStax College is licensed under CC BY 3.0 ↵

2. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed
under CC BY NC SA 4.0 ↵
3. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed
under CC BY NC SA 4.0 ↵
4. This work is a derivative of Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed
under CC BY NC SA 4.0 ↵

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11.10: Respiratory System
Most humans cannot survive without breathing for more than three minutes. If you experiment by trying to hold your breath longer,
your autonomic nervous system will take over and resume a normal breathing pattern. This is because cells need to maintain a
[1]
delicate balance of using oxygen for functioning and releasing carbon dioxide as a waste product.
Although oxygen is critically needed for cell functioning, it is the accumulation of carbon dioxide that primarily drives the need to
breathe. The major organs of the respiratory system function to provide oxygen to body tissues for cellular respiration, remove the
waste product carbon dioxide, and help maintain an acid-base balance. Portions of the respiratory system are also used for nonvital
functions, such as sensing odors, producing speech, and for straining, such as during childbirth or coughing. The respiratory system
includes muscles that move air into and out of the lungs, the passageways through which air moves, and alveoli. Alveoli are
[2]
microscopic gas exchange surfaces covered by capillaries. See Figure 11.14 for an image of the anatomy of the respiratory
[3]
system.

Figure 11.14 Anatomy of the Respiratory System

Capillaries carry deoxygenated blood to the alveoli, where carbon dioxide is released and oxygen is picked up by hemoglobin. The
cardiovascular system transports oxygenated blood from the lungs to the tissues throughout the body where it picks up carbon
[4]
dioxide and carries it back to the alveoli.
A variety of diseases can affect the respiratory system, such as asthma, chronic obstructive pulmonary disorder (COPD),
pneumonia, and lung cancer. These conditions affect the gas exchange process and can result in decreased oxygen saturation levels,
[5]
increased respiratory rates, labored breathing, and other respiratory difficulties.

Anatomy of the Lungs

The lungs are pyramid-shaped, paired organs that are connected to the trachea by the right and left bronchi. Below the lungs is the
diaphragm, a flat, dome-shaped muscle located at the base of the lungs. Each lung is composed of smaller units called lobes. The
right lung consists of three lobes and the left lung consists of two lobes to accommodate the positioning of the heart. As discussed
previously, the respiratory system works in conjunction with the cardiovascular system to transport oxygen and nutrients to cells
[6] [7]
and remove waste from cells and out of the body during exhalation. See Figure 11.15 for an image of the anatomy of the lungs.

11.10.1 https://med.libretexts.org/@go/page/70438
 Figure 11.15 Anatomy of the Lungs
As the body ages, chest muscles lose their strength, and the smaller airways of the respiratory system, called the bronchioles, lose
their elasticity and can collapse. These age-related changes decrease the ability of an older adult to inhale oxygen, resulting in
fatigue and increased difficulty completing activities of daily living. Although some respiratory function can be maintained or
restored through exercise, the aging respiratory system leaves older adults more susceptible to acute respiratory illnesses such as
[8]
influenza, pneumonia, and COVID-19.
Because the respiratory system is necessary for life, if a nursing assistant notices any issues with breathing or a blocked airway,
these concerns should be reported immediately to the nurse. See the section “Choking and Airway Clearance” in Chapter 3 for a
review of interventions for a blocked airway.
Because the cardiovascular system transports oxygenated blood, some symptoms of respiratory distress are similar to
cardiovascular complications such as cyanosis, fatigue, dizziness, and shortness of breath. Exercising and avoiding smoking are
vital for maintaining or improving respiratory function. Table 11.10 outlines common respiratory diagnoses in the aging population,
symptoms to report, and associated interventions provided by nursing assistants.
[9]
Table 11.10 Common Respiratory Conditions and Related Nursing Assistant Interventions

Condition Definition Symptoms to Report Nursing Assistant Interventions

Encourage fluids to thin the

Acute or chronic inflammation of Cough that produces mucus,
mucous, segment ADLs, and
Bronchitis the bronchioles (i.e., small fatigue, shortness of breath, and
position the patient for breathing
airways) chest discomfort
comfort.
Avoid exposure to known triggers
(such as smoke, pet dander, pollen,
A chronic condition in which Coughing, wheezing, chest
mold, etc.). During an asthma
Asthma irritants cause inflammation and tightness, difficulty breathing, and
attack, try to keep the patient calm
narrowing of the respiratory tract shortness of breath
and immediately report breathing
difficulties.

A chronic condition in which Encourage healthy weight and

alveoli hyperinflate, causing Shortness of breath that becomes activity as tolerated, segment
Emphysema reduced air exchange and increasingly more difficult as the ADLs, and encourage the use of
resulting in a lower amount of disease progresses supplemental oxygen if it is
oxygenated blood in circulation prescribed.

Chronic inflammation of the

Shortness of breath, labored Encourage healthy weight, activity
Chronic Obstructive Pulmonary lungs, often caused by smoking,
breathing, dizziness, as tolerated, and smoking
Disease (COPD) chronic bronchitis, asthma, or
disorientation, and cyanosis cessation.
emphysema

11.10.2 https://med.libretexts.org/@go/page/70438
 Encourage smoking cessation,
Chronic cough, coughing up healthy weight and activity as
Lung Cancer Cancer in the lungs blood, shortness of breath, and tolerated; segment ADLs; and
chest pain position the patient for breathing
comfort.

Fever; chills; shortness of breath;

productive cough with green, Encourage healthy diet, activity as
Bacterial Pneumonia Bacterial infection of the lungs yellow, or bloody mucous; sharp tolerated, rest, and taking
chest pain; fatigue; and confusion antibiotics as prescribed.
or disorientation

[10]
View the following YouTube video to learn more about the respiratory system: Respiratory System, Part 1: Crash Course
Anatomy & Physiology #31.

1. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
↵
2. "image1-2-1024x861.jpg" by unknown author is licensed under CC BY-NC-SA 4.0. Access for free at
https://pressbooks.oer.hawaii.edu/humannutrition/chapter/the-respiratory-system/. ↵
3. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
↵
4. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
↵
5. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
↵
6. "image22-1024x704.jpg" by unknown author is licensed under CC BY-NC-SA 4.0. Access for free at
https://pressbooks.oer.hawaii.edu/humannutrition/chapter/the-respiratory-system/. ↵
7. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
↵
8. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
↵
9. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0
↵
10. CrashCourse. (2015, August 24). Respiratory System, Part 1: Crash Course Anatomy & Physiology #31. [Video]. YouTube. All
rights reserved. https://youtu.be/bHZsvBdUC2I ↵

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11.11: Reproductive System
Reproduction is the process by which organisms make more organisms like themselves. Although the reproductive system is
essential to keeping a species alive, unlike other body systems, it’s not essential to keeping an individual alive. Because the
endocrine system controls the hormone levels throughout the body, it has a large role in the functioning of the reproductive system.
Hormone levels affect growth and development, appetite, mood, body temperature, and stress, along with sexual function and
reproductive health. Both the male and female reproductive systems are necessary to reproduce. The organs that are part of both
[1]
reproductive systems are referred to as genitals.

Female Reproductive System

The external part of the female reproductive organs is called the vulva, which covers the opening to the vagina and other internal
reproductive organs. Two pairs of skin flaps called the labia surround the vaginal opening. The clitoris, a small sensory organ, is
located toward the front of the vulva where the folds of the labia join. Between the labia are openings to the urethra and vagina.
When girls become sexually mature, called puberty, the outer labia and the mons pubis are covered by pubic hair. A female’s
[2]
internal reproductive organs are the vagina, uterus, Fallopian tubes, and ovaries. See Figure 11.16 for an illustration of the organs
of the female reproductive system.

Figure 11.16 The Female Reproductive System

Toward the end of puberty, girls begin to release eggs as part of a monthly period called the menstrual cycle. About once a month,
during ovulation, an ovary sends an egg into one of the Fallopian tubes. Unless the egg is fertilized by a male’s sperm while in the
Fallopian tube, the egg leaves the body about two weeks later through the uterus in a process called menstruation. During
menstruation, blood and tissues from the inner lining of the uterus combine to form the menstrual flow, which in most women lasts
[3]
from three to five days.
The menstrual cycle continues until menopause, when levels of estrogen decline and the woman no longer releases eggs. This
usually occurs sometime around the late forties to early fifties. As estrogen levels decrease, women may experience irregular
[4]
periods, hot flashes, night sweats, mood swings, and changes in metabolism.

Male Reproductive System

The external male genitals are the penis and scrotum. The urethra runs from the bladder through the penis to expel urine externally.
Internally, the male reproductive system includes the testes, the duct system made up of the epididymis and the vas deferens, and
the accessory glands that include the seminal vesicles and prostate gland. Testosterone is a hormone that increases during puberty
and is produced in the testes. Testosterone is responsible for causing boys to develop deeper voices, larger muscles, and body and

[5] [6]

11.11.1 https://med.libretexts.org/@go/page/70439
 [5] [6]
facial hair. It also stimulates the production of sperm that fertilizes the egg of a female. See Figure 11.17 for an illustration of
the male reproductive system.

Figure 11.17 The Male Reproductive System

All males are born with a foreskin, a fold of skin at the end of the penis. Some boys are circumcised, which means that a doctor or a
clergy member cuts away the foreskin. Circumcision is typically performed during a baby’s first few days of life based on parental
religious beliefs, concerns about hygiene, or cultural or social reasons. There is no medical necessity for circumcision. See Figure
X for an illustration of the male reproductive organs.
As men age, their prostate enlarges. Because the prostate surrounds the urethra, its enlargement often causes urinary issues such as
the decreased ability to dispel urine, frequent urination, an intermittent stream of urine, and retention of urine in the bladder.
Urinary retention and incomplete emptying of urine from the bladder increase the male resident’s risk of urinary tract infections, so
signs of infection should be monitored by nursing assistants.

1. Hirsch, L. (2019, June). Female reproductive system. KidsHealth. https://kidshealth.org/en/teens/female-repro.html ↵

2. "Blausen_0399_FemaleReproSystem_01.png" by Blausen.com staff (2014) at "Medical gallery of Blausen Medical 2014 is
licensed under CC BY 3.0 ↵
3. Hirsch, L. (2019, June). Female reproductive system. KidsHealth. https://kidshealth.org/en/teens/female-repro.html ↵
4. Hirsch, L. (2019, June). Female reproductive system. KidsHealth. https://kidshealth.org/en/teens/female-repro.html ↵
5. Hirsch, L. (2019, June). Male reproductive system. KidsHealth. https://kidshealth.org/en/teens/male-repro.html ↵
6. "3D_Medical_Animation_Vas_Deferens.jpg" by https://www.scientificanimations.com is licensed under CC BY-SA 4.0 ↵

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11.12: Learning Activities

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11.13: XI Glossary
Bolus: A slippery mass of partially broken-down food that moves down the digestive tract as you swallow.
Chemical digestion: Digestion of food by enzymes found in saliva that break down food particles into smaller components.
Colostomy: Surgery to create a stoma in the colon.
Cyanosis: Blue coloration around the mouth and in the extremities (i.e., feet and hands) that occurs when there is decreased
oxygenated blood flow to the tissues.
Epiglottis: A small flap that closes over the trachea when swallowing to prevent food and fluids from going into the lungs.
Esophagus: The muscular tube from the mouth to the stomach.
Fine motor skills: Small movements such as those in the wrists and hands.
Gross motor skills: Large movements controlled by the legs and trunk of the body.
Incontinence: Failure of voluntary control of urination.
Involuntary muscle: Muscles controlled by the autonomic nervous system, including smooth muscle within the digestive system
and respiratory system and the cardiac muscle in the heart that pumps blood throughout the body.
Large intestine: The long, tube-like organ that is connected to the small intestine at one end and the anus at the other.
Mechanical digestion: Digestion that begins with chewing when teeth crush and grind large food particles into smaller pieces that
are easy to swallow.
Neurotransmitters: Chemicals in the body used for nerve communication.
Osteoarthritis: A medical diagnosis that refers to inflammation of joints due to wear and tear throughout one’s life.
Peristalsis: Contractions that move the bolus through the esophagus, stomach, small intestine, and large intestine.
Pharynx: The hollow tube that starts behind the nose and ends at the trachea and esophagus.
Skeletal muscle: Muscle that produces movement, assists in maintaining posture, protects internal organs, and generates body heat.
Small intestine: A long tube-like organ that connects the stomach and the large intestine where nutrients are absorbed from a food
bolus.
Stoma: A surgically created opening in the abdominal wall where a healthy part of the intestine is attached.
Tendons: Strong bands of dense, regular connective tissue that connect muscles to bones.
Trachea: The hollow tube, otherwise known as the windpipe, that leads to the lungs.
Voluntary muscle: Muscle that a person is able to consciously control.

This page titled 11.13: XI Glossary is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra Sandquist Reuter via
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